Could you tell us about your experience teaching patient safety to nursing students at Texas Women’s University?

I’ve been at Texas Women’s University full time since 2012 and realized a couple of years ago that there wasn’t much patient safety being taught in the undergraduate curriculum. I knew that we needed to put something in, so I started doing a research study where we embedded didactic as well as clinical patient safety concepts into the curriculum, and we’ve just finished our first semester. Students get the general patient safety overview and also discuss medical errors, near-misses, just culture, human factors, etc. Then the clinical faculty will observe them in a clinical setting, looking for things that either the students don’t do right or things they see nurses not doing right to take back and discuss in relation to those same concepts.

I also performed a needs assessment and found out that some faculty may not be fully up to date about patient safety. Some need to update their knowledge, others need greater confidence in teaching what they know.

What it comes down to is that we are redoing the entire undergraduate curriculum and there will be threads of patient safety throughout.

"They may think, 'Okay, we just have to keep the patient safe,' but it is far more than that."

—Susan Mellott

What made you interested in patient safety?

That’s easy. I cannot separate, as Don Berwick said at the 2017 Patient Safety Congress, patient safety from quality. I’ve always been involved with patient safety, but I see now that I’m teaching more of a need to move the courses over to the patient safety side. Human factors just keeps pulling me more and more into that and if I could keep working with human factors and patient safety, I’d be in seventh heaven.

How do we move forward to promote a culture of safety?

First of all, there are people who don’t understand what a culture of safety is. They may think “Okay, we just keep the patient safe,” but it is far more than that. Learning that Just Culture is a process, not the individual that makes mistakes, and that everybody will make a mistake at some point in time is so important. We need to look at the processes and refine those so that we prevent mistakes from happening or, if something does happen, we put in a safeguard to prevent it from getting to the patient. That’s one big factor.

People also fail to understand how you move from a basic mistake over to intended behavior and that there are different degrees as you move over. The way I teach it is: You know what you are supposed to do and you do it. But then you talk on the phone while you are driving with the idea that surely an accident won’t happen to me so you are willing to take that little bit of a risk. All of us in health care know that people find shortcuts and ways to get around doing things and so when we do that, we move into the same category as talking on the phone while driving.

This year we are celebrating the 20th anniversary of NPSF. What do you think that means for the field of patient safety?

When Total Quality Management came out, no one knew what that was, but people were trying to put it into shape to have a quality culture within their organizations. Then in 1999, To Err Is Human came out, and many in the health care community said “Let’s drop this quality thing and get this patient safety culture figured out.” Many places still do not have a patient safety culture and they don’t have a quality culture either. The two things together, as I said before, I don’t think can be separated. The problem is that it has not been ingrained into a lot of organizations because the leadership focuses on other priorities like the financials, etc. However, with this being the 20th anniversary and with NPSF joining with IHI, people are going to take notice. To have the merger take place on the 20th anniversary is like a new celebration.

Stand Up Stand Out is an occasional feature on the blog highlighting the work of organizations that belong
to the NPSF Stand Up for Patient Safety program. In this post, read about what one Texas health system

is doing to improve palliative care.

Baylor Scott & White Health, a not-for-profit health system based in Texas, is a founding member of the IHI/NPSF Stand Up for Patient Safety program and has recently partnered with Ariadne Labs to roll out their Serious Illness Conversation and Care Planning Program across their system. Robert L. Fine, MD, FACP, FAAHPM,Clinical Director, Office of Clinical Ethics and Palliative Care at Baylor Scott & White Health, spoke to us about the genesis of the palliative care movement and how the program has initially influenced patient safety across their health system.

Why did Baylor Scott & White partner with Ariadne Labs to implement their

Serious Illness Conversation and Care Planning Program?

The easy answer is that they had a complete, scalable, evidence-based product ready to go to help improvecommunication between patients and providers.

The deeper story, however, is the collective cumulative experience that led to the development of palliative care in first place. One of the earliest studies to suggest such a need was the SUPPORT study, published in JAMA in 1995. This study involved 9,000 seriously ill patients with a six-month mortality rate of 50% admitted to five major teaching hospitals. These weren’t hospice appropriate patients—at least not on admission—these were people with a 50% chance of survival and, in fact, half did survive. However, for the 50% of patients who died, the study revealed glaring care deficiencies leading to significant confusion about goals of care (with much unwanted treatment provided) and significant suffering. The SUPPORT study thus revealed a special sort of patient safety concern and care deficit.

At the root of this care deficit was poor communication. Many of us focusing on end-of-life care via ethics or hospice consultation came to understand that hospice could not serve patients in common circumstances like those found in the SUPPORT study until very late in the patient’s journey, and ethics consultation could largely work on only the moral dimensions of care. Some other sort of service not necessarily tied to definite terminal illness or ethical uncertainty/discord was required.

The notion of palliative care as distinct from hospice was just starting to evolve at that time and the SUPPORT study lent great credence to the need. In fact, I attempted to start a small palliative care program at Baylor University Medical Center in 1995, but the program was terminated before we could serve our first patients. It would be several more years before we could get our palliative care service line established. Palliative care as a specialty is now growing rapidly, but we’ve all realized that we can’t train palliative care doctors, nurses, and other professionals fast enough to serve every seriously ill patient who might benefit. We must help non-palliative care professionals develop better primary palliative care skills, such as better communication skills.

So, how can we do that? The reality is that busy physicians aren’t going to take a multi-day training to do it and non-palliative care specialty training will never include the intense communication training that is so much of the focus of a palliative medicine fellowship. However, non-palliative care professionals can and will participate in shorter training with role-play exercises over a few hours accompanied by ongoing coaching. BSWH chose the program from Ariadne Labs because they had the evidence-based solution we were looking for.

What does the Serious Illness Conversation and Care Planning Program consist of?

There are three basic components:

Tools that provide a scripted checklist approach to guide the clinician who isn’t comfortable with having these types of serious conversations;

Education for health care professionals using the tools; and

Systems change to help identify appropriate patients and to build the tools into the EMR so that any practitioner can look at the chart and be both guided in the conversation and see what has been previously discussed by others following the same conversational script.

It has been demonstrated that patients and doctors like the tools, it helps make conversations more complete, and the data are retrievable. This is a pretty big systems change and Ariadne has never taken it to a system as big as ours—this will be the first.

How are you rolling the program out across your system?

Systems change and EMR implementation is critical. It would frankly be easier in a system that has one EMR, but at Baylor Scott & White we have two different major EMRs. Another challenge is our sheer size and geographic spread. We are also one of the larger nonprofit systems in the country, the largest in Texas, and we have thousands of physicians, advance practice nurses, and others to be trained.

At the same time that we have been building the necessary tools into our EMRs, we are also training our palliative care experts to train others in the use of the SICP tools and process. I’ve observed that just because a palliative care professional is an expert communicator with patients of families, that doesn’t guarantee they will be an expert trainer, so the notion of “train the trainer” is very important. Each trained facilitator can then train three learners in three hours. Of course, the trainer needs to be available going forward to provide ongoing coaching when needed. It is a bit daunting given our size, but we see it as a perpetual task that we are slowly and deliberately weaving into the fabric of our organization. It is a project in perpetuity and we want this program to be self-sustaining.

What has been the reaction among team members to the new program?

We don’t teach much about end of life in medical school, especially not the differences in communication between those with less serious illnesses versus more serious illnesses, and this training is benefiting both palliative care professionals and those who may not be as comfortable having these conversations. The palliative care professionals, even though already skilled in serious illness conversation, are very excited. Some have said that it has actually shortened their goals-of-care conversations because the script helps to focus the conversations. We are also starting to hear from some early adopter non-palliative care professionals we have trained saying that they don’t need the palliative care team as often to have these conversations. I think some palliative care professionals might see that as a threat, but at BSWH we don’t!

Out in the community of doctors, there are those who haven’t been trained but are excited to be trained ASAP. There are others who feel they don’t have time to learn this right now, but we are working on how to encourage everyone to take the time for trainings.

How do you think this program will impact patient safety across your system?

It has already. When it comes to the structural impact, you see it by being able to open up the EMR and having a link at the top of the patient banner directly to the SICP script and answers. All you have to do is click to see what answers the patients gave. This is the beginning of real cultural change.

It is so vitally important because a lot of programs from the mid to late 1990s on have emphasized preventing bad death, meaning a patient who received unwanted treatment, was separated from their family at death, experienced emotional and spiritual distress, had poorly treated pain, and experienced many other treatment deficits as well. That is a patient safety problem. If death comes, we should ideally provide what I refer to as “safe passage.” For example, if someone says ‘When I die, I want to go to heaven without your machines’ then we ought to be able to know that and offer them a safe passage to heaven or whatever their wishes may be. We use the idea of safe passage frequently with patients and families facing mortality because it is an idea that people get.

We recently had a palliative care physician say to us, "I found all this information that I normally don’t have when I’m consulted. It was in the SICP section of the EMR. When I was called in as a consultant, the information present allowed me to sit down with the patient and family and say 'Based on the information you gave to your oncologist, I can suggest we do the following…'" The information not only gets to the right person at the right time, but it also gets dispersed to the whole team. We see this program continuing to influence patient safety as time goes on and the amount of trainers and trainees grows.

What are some of the main challenges for Michigan hospitals and health systems?

With regard to challenges related to hospitals and health systems and implementing both patient safety and quality activities, there’s so much to do. The opportunities to improve quality and safety are never ending. There is a tremendous amount of reporting burden that draws time and energy that, quite frankly, diverts attention from the work of improvement.

Patients are sicker than they have ever been in hospitals, and that draws the main focus of everyone. If you think about where improvement should happen, it shouldn’t be in the quality department or the safety department; it should be at the bedside. If you are caring for very sick patients, it’s one more thing to try to work into your day.

Could you tell us about your experience on the National Patient Safety Foundation Board of Advisors and what you look forward to as you make the transition to the IHI Board?

"If you think about
where improvement should happen,

it should be at the bedside."
—Sam Watson

Having the opportunity to participate in the NPSF Board of Advisors was a tremendous experience. To be surrounded by people who are so patient safety oriented and talented was a very humbling experience for me. I learned so much by listening to conversations around the table. The insights that people brought and the perspectives they had, you don’t get unless you are in that sort of environment. Looking ahead to the opportunity to serve on the IHI Board, again, it’s a very humbling thought considering the history of that organization and what it has brought to the world of improvement. To take that and magnify the work of safety in the NPSF mission is a tremendous opportunity.

What made you interested in joining the patient safety field?

My path to the world of patient safety was not direct. I’m actually a laboratorian, and my background is in clinical lab science, which is one of the few areas of health care that has been highly reliable, especially the blood blank. Quality is in everything we do. Transitioning into the quality and safety realm within the hospital setting, I found that the opportunity to influence care is profound in that you can bring everyone together to work on the problems of quality and safety.

As with many of us, there’s also personal experience—having a loved one who was affected by diagnostic error and to see what that meant to our family—that creates an amount of passion that you can only get, I think, by experience.

What is something that most people don’t know about you?

Outside of the joy in doing the work I do, I race mountain bikes. I enjoy the adrenaline rush of hurtling through the woods on a single track and have been racing for over 25 years. As of late I have focused more on epic races, which are 50 miles or more.

The merger of IHI and NPSF took place as NPSF marked its 20th anniversary. What are your thoughts on that anniversary and how the patient safety field has changed?

Celebrating 20 years of the work NPSF has been doing is 20 years young. This is a nascent field. If you think back to 1999 with the IOM report, and of course Dr. Leape’s work before that, NPSF has created a vibe around patient safety, without which we wouldn’t have been propelled as far as we have. With everyone at the table, including providers, patients, and the medical device manufacturer community, I think that 20 years has resulted in so much change that otherwise wouldn’t have been accomplished.

You were a co-chair of the Board subcommittee that developed Call to Action: Patient Safety Is a Public Health Crisis and Patient Safety Requires a Public Health Response. Could you tell us about that experience?

We had a subgroup of the Board of Advisors that came together and generated the Call to Action that, ultimately, the NPSF Board of Advisors and Board of Directors supported. The concept of this Call to Action is to raise awareness around the deficits that we still have in supporting patient safety work. To look at it as a public health issue is really unique from the standpoint of understanding that it’s not a doctor problem or a hospital problem; it is as critical as safe drinking water. Unless we magnify this issue to that level, it won’t get the attention or the resources it deserves.

To learn more about the American Society of Professionals in Patient Safety, visit www.npsf.org/aspps.

As Jessica Behrhorst, system director of quality and patient safety at Ochsner Health System admits, Root Cause Analysis and Actions (RCA2) seemed like an intimidating process before they started implementation in their 13-hospital health care system with more than 1,000 employed physicians and a non-employed medical staff of over 2,000. However, after taking the time to learn about RCA2 and teach it to their team, the health care staff at Ochsner is a lot more open to talking about the process, which has now been added to their regular toolkit. But the question is: how did they get there?

At this year’s NPSF Patient Safety Congress, Ms. Behrhorst and Richard D. Guthrie, Jr., MD, CPE, chief quality officer at Ochsner Health System, will describe their journey through the implementation of the new Root Cause Analysis and Actions model and what they’ve learned in the process.

“When we started in 2015, we were very aware that we couldn’t do RCA2 in a vacuum—it had to be part of a larger cultural change,” said Ms. Behrhorst. “We could put the pieces into place, but if we didn’t have a culture of reporting or trust from our staff that we were going to do something with those reports, we knew we wouldn’t be successful.”

One of the first successes they saw was a significant increase in the number of RCAs being performed including some RCAs on good catches that they may not have done in the past. For example, the team at Ochsner had seen several events where surgical equipment was coming back with bioburden. The equipment never touched or harmed a patient and was sent to get reprocessed, but staff started reporting it, so they used the sterilization process for the RCA2. The team had found enough risk by using the risk-based prioritization matrix that they thought a change in the process was necessary, allowing them to effect change in an area where a patient could have been harmed.

Richard Guthrie,

chief quality officer,

Ochsner Health System

Jessica Behrhorst

system director

of quality and

patient safety,

Ochsner Health System

Many of the tools Ochsner uses for RCA2 have come directly from the 2015 NPSF report, RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. Ochsner Health System created three distinct presentations based on the report in order to get the health care team up to speed and on board with the complex processes: one was created for leaders in the RCA2 team, another is specifically for team member briefings, and one holds the electronic version of the tools from the RCA2 report.

Not only has implementingRCA2 proven to be successful within their own system but it has also become a way to share events and experiences with other facilities. Every month, Ochsner hosts a system quality meeting that includes chief nursing officers from across the system, their vice president of medical affairs, and performance improvement and pharmacy leaders. In that meeting, participants started sharing RCA events and the findings from those RCAs. As a result, teams started learning a lot from the sharing, particularly in instances when they found out that other facilities had faced similar events and could share tools to help mitigate the problem. The lasting effect was helping systems recognize that they are not operating in silos.While some areas of health care may fall into the ultra-safe category, where the goal is to avoid risk altogether, other areas may be categorized by the need to manage or mitigate risk.

In the spirit of not operating in silos, Session 301 will share lessons learned from the two years they have implemented RCA2, so that others may learn from their challenges and successes.

Communication between individuals to leverage what is known in all types of care environments can be difficult. Whether at the organizational or team level, defined goals, processes and expectations help to shore up what information is shared, how it is delivered, and what is done with it.

Two sessions at the 2017 NPSF Patient Safety Congress in Orlando will provide insights into effective information sharing in ambulatory care. They target two important initiatives that benefited from defined methods of information sharing—organizational learning from adverse events or near misses and patient transitions from the hospital to primary care teams. The speakers will discuss their experiences to highlight value associated with taking the time to build processes to apply information and knowledge in support safe care.

Improvement through sharing lessons learned

PeaceHealth recognized that the work done to improve processes wasn’t reliably assimilated to help their organization learn. “We have learned that robust event investigation requires a system-level structure to triage outpatient safety events,” said Andrea Halliday, MD, patient safety officer, PeaceHealth.“Otherwise, problems are solved on a clinic level and we miss an important opportunity to learn from our events and to spread the lessons learned.”

To help their outpatient clinics design and implement improvement strategies drawn from system-reported adverse events and near misses, PeaceHealth:

Established a leadership team to track and discuss events

Launched and supported communication opportunities over time

Encouraged accountability through documented improvement action plans

Monitored the initiative to track its impact

This structured approach didn’t leave learning to chance. It didn’t assume that sharing was happening. Instead the organization committed to a process that raised awareness of the importance of learning from what goes wrong.

"We have learned that robust event investigation

requires a system-level structure

to triage outpatient safety events.".

—Andrea Halliday, MD

Session 305 will discuss the methods used to enable improvements across the ambulatory care continuum of a large health care system.

Safe patient transition from hospital to the community

Transitions are ripe for communication gaps, missteps, and misunderstandings. Transitions from one environment to another offer extra challenges as the team who knows the patient best can be disconnected from their care due to the changed location. Adding to the complexity, the patients may not always be effectively engaged in the process to confirm that they have the information they need to ensure their safety once outside the hospital (See Horwitz et al. 2013)

Handoff tactics such as standardized information bundles and checklists have been noted to make information sharing more reliable in the hospital and after discharge. Breakout session 505 builds on those successes to highlight an improvement strategy at Iora Health for use as patients enter the primary care management space: transition navigators.

“Our experience has shown that involvement of primary care teams when patients are hospitalized is invaluable,” said Sumair Akhtar, MD, MS, associate medical director, culinary extra clinic, Iora Health. "We understand that in a busy practice, it is nearly impossible for most PCPs to directly engage with inpatient teams on every occasion, therefore, to improve the primary care team's influence and involvement in inpatient care, we have proposed a multidisciplinary model that leverages team nurses and clinically savvy non-clinicians (with solid process and simple tools) to be the liaisons between the patients, caregivers, and inpatient and primary care teams.”

The speakers will discuss how transition navigators help to ensure that communication is clear and concerns are addressed when patients transfer out of the acute care environment. They will share tools and measures that have supported the development of this innovative member of the care team.

Both these sessions will discuss ways to ensure that information and knowledge sharing wasn’t left to chance. They support the value of resourcing and tending to processes of transferring information to ensure that organizations and care teams are prepared to safely serve patients and families.

Patient Safety Beyond the Walls of the Hospital is one of six Breakout Tracks featured at the NPSF Congress May 17-19. View more details.

What methods do you employ at your organization to support effective information? Comment on this post below. Note: to post a comment you must be logged in. Register or log in.

Lorri Zipperer, MA, is the principal at Zipperer Project Management in Albuquerque, NM, specializing in knowledge management efforts and bringing multidisciplinary teams together to envision, design, and implement knowledge sharing initiatives. Among her publications, Ms. Zipperer recently served as editor for two texts, Knowledge Management in Healthcare and Patient Safety: Perspectives on Evidence, Information and Knowledge Transfer, both published in 2014, and as a co-editor for the 2016 publication Inside Looking Up, published by The Risk Authority Stanford.

The Joint Commission’s 2012 Sentinel Event Alert #49 on the safe use of opioids in hospitals came as a wake-up call to many clinicians and leaders. Although opioids can be largely safe for many patients, the alert warned of dangerous potential side effects, particularly respiratory depression.

Just a few months after the release of that alert, an event related to respiratory depression and opioid analgesics resulted in a patient’s death at Wake Forest Baptist Medical Center in Winston-Salem, NC. A root cause analysis was conducted, and one of the recommended actions was to use surveillance monitoring of patients receiving opioids. That led to a major initiative resulting in widespread use of surveillance monitoring in multiple facilities.

Kristina Foard RN, MSNEd, SCRN, Nurse Practice Specialist, joined the effort to identify the best system for Wake Forest and assist with the implementation. She and Dr. Robert Weller, physician champion for the surveillance monitoring deployment and response to SE#49 at Wake Forest, were asked to evaluate some of the available bedside monitoring systems that would allow for surveillance monitoring.

Historically, medical/surgical nurses have relied on spot-checking their patients by collecting and recording vital signs every 4 to 8 hours. Of the opioid-related sentinel events reported to TJC between 2004 and 2011, 29% were related to improper monitoring of the patient. As early as 2011, the Anesthesia Patient Safety Foundation was calling for continuous electronic monitoring of oxygenation and ventilation in patients on opioids.

Once the Wake Forest team had evaluated the options, they began a 20-week pilot program on a neurosurgery unit. Because they wanted to capture as much data as they could during the pilot, they decided that any bedded patient on that unit would be placed on continuous monitoring. At the end of the pilot period, they evaluated the data with the nursing staff and with patient and family input. When they presented the results to their leadership team, the decision was made to deploy surveillance monitoring broadly throughout their institution.

“One important lesson we learned by monitoring everyone is that risk stratification is extremely difficult,” said Ms. Foard. “We like to look at comorbidities and whether patients are opioid naïve or opioid tolerant, if they are obese or have Obstructive Sleep Apnea (OSA), because things like that put them at higher risk for opioid induced respiratory depression. But, in fact, many of the interventions triggered by continuous monitoring were not necessarily opioid-related. We also identified cardiovascular events including tachy- or bradydysrhythmias and hypo- or hypertension that we may have failed to identify if we hadn’t been doing surveillance monitoring on all patients.

“We elected then to apply surveillance monitoring as our standard of care. If you got bedded on a unit that had the monitoring, you were placed on monitoring and the provider had to write an order to remove you,” she added.

Some providers have asked for development of risk stratification that would allow for selective rather than surveillance monitoring of all patients, and this continues to be a barrier to overcome, Ms. Foard said. Both physicians and nurses commonly suggest that “young” and “healthy” patients did not need continuous monitoring, but an effective risk score to apply selective monitoring is not yet available.

Another challenge was alarm fatigue. The system cannot do the kind of critical thinking that nurses do, for example, so the team had to take care in setting wide enough parameters that would minimize non-actionable alarms without missing true deterioration events. These parameters were tested and optimized relative to alarm frequency. Ms. Foard and Dr. Weller also collaborated with their Rapid Response team to develop a flow chart to help the nursing staff manage and respond to alerts.

Ms. Foard and her co-presenter will discuss the technical challenges as well as the cultural challenges involved in such an initiative.

“Leadership support and buy-in from managers of the unit is an absolute must,” she said. “Without manager support, you’re not going to get the buy-in from the bedside nurses. Even beyond that, having the executive support for that cultural shift, especially a shift that impacts providers and nursing staff, is critical.”

Kristina Foard and her co-presenter, Karen Luse, MSN, will talk about this initiative in Breakout Session 304: Surveillance Monitoring on General Care Floors, at the 19th Annual NPSF Patient Safety Congress. See details of the full Congress program.

Patients and their families are critical members of the health care team and are uniquely positioned to observe the behaviors of clinical team members. Organizations who listen will find that patients’ stories can be sources of valuable information that can promote improvements in care.

"Study results remind me how important it is

to engage patients and families in our efforts

to promote safe care."

—Gerald B. Hickson, MD

Fifteen years ago, our Vanderbilt research team recognized that if patients’ unsolicited complaints were documented, coded, and aggregated, they reliably identified a small subset of physicians (2-8% by specialty) who accounted for more than 75% of malpractice claims and costs. Our early studies, however, did not answer an important question: Is high claims risk simply about making patients and families unhappy or is there something more?

In a study published in JAMA Surgery, we asked if patients who received care from surgeons associated with high numbers of complaints about perceptions of disrespect were more likely to experience complications from surgery than patients who were seen by surgeons who attracted few, if any, complaints.

We used data from the American College of Surgeon’s National Surgical Quality Improvement Program (NSQIP®) and our Vanderbilt Patient Advocacy Reporting System (PARS®), which uses unsolicited patient complaints to identify physicians with a high risk for malpractice claims. The study design allowed us to look at a surgeon’s complaints for 24 months prior to the target surgery and any postoperative complications in the 30 days post procedure. Seven medical centers that participate in both PARS® and NSQIP® contributed 817 surgeons and more than 32,000 surgical procedures to the study.

The analysis revealed that patients whose surgeons were associated with the highest numbers of complaints had almost 14% more postoperative complications when compared with patients seeing surgeons viewed as respectful, even when the analysis controlled for patient, surgeon, and operative characteristics. If extrapolated throughout the US (27,000,000 surgeries annually), failures to model respect and communicate effectively contribute to more than 350,000 additional surgical site infections, cases of sepsis, and urinary tract infections, representing more the $3 billion in additional costs with no way to calculate the magnitude of the impact on patients and families.

Study results remind me how important it is to engage patients and families in our efforts to promote safe care. Patients experience our dysfunctional systems and unprofessional clinicians. The question is, when they are willing to share, are we willing to listen, learn, and respond? Patients do not always describe their observations in "proper" medical language and as a result are too often discounted or ignored. Our results make it clear, however, that what is experienced and reported is valuable and serves to identify surgeons who have difficulty working with others contributing to surgical complications and excess malpractice claims risk. We suspect that our research team will identify similar findings in ICUs, emergency rooms, cath labs and wherever medicine is practiced.

Results also answer the question that our team has pondered for 20 years: Is high claims risk just about the random bad outcome and routinely making patients and families unhappy? The answer is no. It is not "just" about modeling disrespect toward patients. The same behaviors reported by families are also experienced by medical team members who can become distracted, lose situational awareness and willingness to speak up or ask for help when needed contributing to thousands of avoidable surgical and medical complications each year.

The good news is that our experiences in supporting interventions, with more than 1800 high-risk clinicians from our national partnerships, has taught us that most physicians modeling patterns of disrespectful behaviors (approximately 75%) just need to be made aware that they stand out (see Pichert et al. 2013). However, setting the stage to deliver “awareness” is critical and requires leadership that does not blink (rationalize) when the disrespectful surgeon is perceived to have special value. It also requires leadership that will commit to building the infrastructure to support professionals who are willing to deliver peer-based comparison data to help their at-risk colleagues pause and reflect on how their behaviors are experienced by others. The work is not for the faint of heart but is professional and aligns with the NPSF commitment to creating a world where patients and those who care for them are free from harm.

Have you witnessed disrespectful behavior that you think contributes to the quality of care? Comment on this post below. Note: to post a comment you must be logged in. Register or log in.

Gerald B. Hickson, MD, is senior vice president for quality, safety and risk prevention and Joseph C. Ross chair for medical education and administration at Vanderbilt University Medical Center and a long-serving member of the NPSF Board of Directors.

What are the biggest challenges you face as a patient safety manager at Palo Alto Medical Foundation?

“One of the biggest challenges I face is the fact that I am a not a clinician. While it is not a requirement for my job, it has presented some challenges in terms of understanding various clinical processes and terminology. However, in an effort to mitigate this, I have developed strong partnerships with various providers and leaders so that we can work together in developing effective and collaborative solutions for patient safety. Without the help of the physicians, nurses, pharmacists, medical assistants, and others, I wouldn’t know where to even begin in terms of defining and developing meaningful measures for patient safety at PAMF. It’s been a wonderful partnership, and I hope to continue this legacy as I transition into my new role as a patient safety consultant for Sutter Health.”

Tell us why you became a member of ASPPS?

“I joined ASPPS in hopes of connecting with other nonclinical professionals like myself. It’s extremely important for me to connect with others who share my passion for patient safety. I feel that the more people I can connect with and learn from, the more effective I will become at leading change. I have dreams of becoming a national leader in patient safety, and I believe that I can achieve this goal through the learnings and networking opportunities afforded to me as a member of ASPPS.”

What made you interested in the patient safety field?

“Believe it or not, I actually fell into the patient safety profession. I worked at Stanford University Medical Center in the field of Neuropsychology for 11 years, but then I decided to try something completely different and pursue an MBA. Shortly after graduating, a former business school classmate of mine reached out to me regarding a potential opportunity at her hospital. After speaking with her and the director of clinical quality improvement, interviewing, and learning more about the job, I realized that it was an opportunity that I just couldn’t pass up. The job was for a patient safety officer role at Doctors Medical Center in Modesto, Cal. I absolutely loved it, and it was through this first experience as a PSO that I found my niche in health care. And the rest, as they say, is history.”

In your opinion, what is the future of the patient safety field?

“There are a number things that I anticipate will happen in the future:

“One, I believe that as the patient safety field continues to grow, more people will be engaged in this work, particularly with frontline staff. They have the greatest perspectives and the best ideas, but sometimes their voices aren’t heard enough. As leaders in patient safety, we must continue to support a culture that encourages their engagement. Because in the end, their engagement will translate into providing safer careto our patients.

“Two, I also think that from a consumer standpoint, patient safety will become increasingly important. Now that there is more research in this area, and that patients are utilizing social media to share their experiences, the general public will demand safer and more reliable care.

“Lastly, I believe more nonclinical leaders will join the patient safety movement. It’s such a rewarding and exciting profession to be in, which are elements that many professionals want out of their career. What can be intimidating, however, is the clinical aspects as I mentioned earlier. But through strong partnerships and dedication, I know that it can be done. I’d like to think that I’m living proof of that.”

MOE is Palo Alto Medical Foundation's

patient safety mascot

What keeps you up at night?

“The most worrisome to me also happens to be the most motivating. The fact that medical errors remain one of the leading causes of death in the United States is mind-boggling to me. Even in this age of technology, we are still prone to error when it comes to patient safety. To me this suggests that perhaps technology isn’t always the answer, and that there are still creative, yet simple solutions that are waiting to be discovered.

“I love exploring ideas with interdisciplinary groups, and figuring out simple solutions that we can try and test today. For example, as a fun and inspirational way to engage employees with our patient safety efforts, we created a patient safety mascot exclusively for use at the Palo Alto Medical Foundation. We then built on the idea of using the mascot to engage staff by holding a “name the patient safety mascot” contest, where the winner earned a lunch for his or her department and a feature in the monthly newsletter.

“The winning entry was MOE, which stands for “Mindful of Environment.” MOE has become quite the celebrity, making cameo appearances in promotional videos and publications, as well as branding for patient safety awards and acknowledgments. One of our leaders even had MOE made as a plush toy that she keeps in her office for everyone to enjoy. MOE’s presence has truly enhanced engagement, and lends well to the culture of safety at Palo Alto Medical Foundation.”

What is something unique about you?

“I am a retired professional salsa dancer. I used to perform, compete, and teach with a dance team in the Bay Area. While I don’t dance anymore, I stay connected with the team as they remain as some of my closest friends.”

Stand Up Stand Out is an occasional feature on the blog highlighting the work of organizations that belong
to the NPSF Stand Up for Patient Safety program. In this post, read how one New York City health center
is making strides to overcome low health literacy.

The National Patient Safety Foundation has long advocated for patients and family members to be regarded as integral members of the health care team. When patients are actively engaged, they can help improve patient safety and experience better outcomes.

Yet getting patients engaged in their care is more challenging than it might appear. Barriers to engagement are still common at many levels of the health care system, with a 2014 report from the NPSF Lucian Leape Institute citing low health literacy as one of the chief barriers.

Health literacy has been defined as “the degree to which an individual has the capacity to obtain, communicate, process, and understand basic health information and services to make appropriate health decisions.”

The most commonly cited data suggest that only 12% of English-speaking adults in the U.S. are at a proficient level of health literacy. That means many of us struggle to comprehend care plans, medication regimens, and follow-up instructions.

To ensure that patients are able to understand important health care information, it is critical that providers recognize the nature of patients’ health literacy challenges and implement strategies to promote clear health communication. Ask Me 3, a program of NPSF, is designed to improve the lines of communication among patients, families, and health care professionals. The program encourages patients to ask the following three specific questions of their health care providers to better understand their health conditions and what they need to do to stay healthy. The program encourages health care providers to use this framework to be prepared to answer the questions.

The Ask Me 3 program is one of the
tools being used at NYC Health +
Hospitals/Cumberland to improve
communication between patients and
health care providers.

1.What is my main problem?

2.What do I need to do?

3.Why is it important for me to do this?

Through the use of these questions, Ask Me 3 empowerspatients to become more involved in their health care, organize the provider-patient conversation, focus discussion on the answers to key questions, and help patients acquire the information they need to take care of their health.

Staying Focused in Brooklyn

NYC Health + Hospitals/Cumberland, a Gotham Health Center, in Brooklyn, NY, is one of many health care organizations that have implemented the Ask Me 3 program to address health literacy. As part of NYC Health + Hospitals, the largest public health care system in the country, Cumberland has more than 57,670 patient visits every year from all walks of life and cultural backgrounds. Marlene Dacken, RN, patient safety officer, points out that “empowering patients to be active members of the patient/provider relationship and ensuring that communication is clear are essential components of patient safety.”

The hospitals under the auspices of NYC Health + Hospitals have been long-time members of the NPSF Stand Up for Patient Safety program. As part of a larger effort to engage patients in their care, Cumberland introduced the Ask Me 3 program in adult primary care clinics, specialty care departments, and pediatrics.

Overall, approximately one-third of patients at Cumberland have used the program, according to Cynthia Boakye, MD, medical director. “For adult medicine, we try to give it to every patient,” she says. “Those who choose to use it fill out the form and organize their thoughts before they see the provider.”

Before rolling out the program, the Cumberland team ensured that all staff members were on board by providing training on health literacy and the program. The program has become a part of the culture of care at Cumberland with ongoing training of staff and all new hires.

A nurse or nursing assistant explains the program to the patients and provides them the questions on a form. Physicians refer to the form during the visit and are able to correlate the information they want to tell the patient to the patient’s questions.

“Staff members believe that the program really helps the patient get focused on what they want to ask the physician during the encounter,” says Ms. Dacken. “This helps outline their process to keep focused on what their concerns are.

“I started to use it myself, because even as a nurse, sometimes you do forget or you lose focus,” she adds. “As a patient, the communication is often physician-directed, the provider asking all the questions, but there are questions not on the health provider’s radar that may be on the minds of patients.”

The team has also developed a program called Take the Pledge, Take Your Meds, to improve medication adherence, another common issue in outpatient care.

Results of these efforts are so far anecdotal, with patients and staff both reporting positive feedback. “The patients think that it’s a good idea,” said Dr. Boakye. “It helps them focus on what they have to ask the physician and keeps everything in alignment so they are not diverted.”

NPSF offers complimentary Ask Me 3 materials and resources to organizations interested in implementing the program. Posters and fliers in English and Spanish are provided, along with an implementation guide and other materials. In addition, a new educational module is now available to help educate clinicians and staff regarding health literacy and the Ask Me 3 program.

Some 2,000 individuals have downloaded the materials in the past year, and the Ask Me 3 program continues to be one of the most frequently visited areas of the NPSF website.

“We are very pleased with the growing interest and use of this program over the past few years,” said Patricia McGaffigan, RN, MS, senior vice president for program strategy and management and chief operating officer of NPSF. “We see it as a very useful addition to other tools organizations may be using with both patients and health care professionals to better engage and communicate with their patients.”

It is a challenging time to be working in health care. There are new care delivery models being developed, declining reimbursements due to price competition and narrowing of insurance networks, and medical practices are consolidating. Meanwhile, use of electronic health record technology has dramatically increased the clerical burden for providers, and staffing is increasingly difficult with national shortages of physicians and nurses in certain specialties. Furthermore, there is constant pressure for health care organizations to implement new quality metrics and requirements for public reporting, along with the ever-present competition to maintain high patient satisfaction scores. (See Shanfelt and Noseworthy 2017.)

Burnout contributes to decreased well-being,
lower retention rates, higher staff turnover,
low morale, and a lack of cohesiveness in the
organization as a whole.

Successfully navigating these challenges requires engaged and resilient leaders and providers who are able to effectively handle both the business aspects and the stress associated with this level of change. Burnout is a key factor impacting the engagement of health care providers across specialty areas:

Approximately 54% of doctors are burned out to some degree, which is an increase from 33-40% of doctors reporting such symptoms just a few years ago.

There is a strong business case for reducing burnout and increasing engagement in health care. Burnout contributes to decreased well-being, lower retention rates, higher staff turnover, low morale, and a lack of cohesiveness in the organization as a whole. Physician burnout has been shown to influence patient care, patient satisfaction and patient safety, and burnout is positively correlated with a physician self-reporting suboptimal care.

One study showed that even just a one-point increase in the exhaustion and cynicism components of burnout resulted in a respective 5% and 11% increase in likelihood of reporting an error. Conversely, hospitals in which burnout was reduced by just 30% had a total of 6,239 fewer infections for an annual cost savings of up to $68 million.

Leaders should focus on both organizational and individual factors, with a recent meta-analysis suggesting that the benefits derived from individual programs would get a boost by also adopting organizational-directed approaches. Three organizational-directed approaches that have been shown to build engagement and reduce burnout are as follows:

Build More Job Resources

Job resources are the motivational aspects of a person’s job that energize. Leaders should focus in these five areas:

Increase autonomy

Foster high-quality connections with colleagues

Create opportunities for excellence (people want to be both challenged and part of something meaningful)

Offer FAST feedback that is frequent, accurate, specific, and timely

Maximize leader support

Minimize Job Demands

Job demands are the aspects of your work that take sustained effort and energy. Not all job demands are created equal, and research points to three specific ones to be minimized because they accelerate burnout and kill engagement:

Role conflict (“I have received conflicting requests from two or more people”)

Role ambiguity (“My duties and work objectives are unclear to me”)

Organizational constraints/unfairness (“I had to go through many hassles to get projects/assignments done”)

Foster Personal Resources

An important personal resource for leaders and their constituents to develop is resilience. Resilience can be taught, and it is built through a set of core competencies that enable mental toughness and mental strength, optimal performance, strong leadership, and tenacity (resilient people give up less frequently when they experience setbacks).

Given the strong connection to patient safety, patient care, and patient satisfaction, it makes good business sense for health care organizations to implement strategies to reduce burnout and build engagement. The time to take action is now.

Do you know of an organization that is taking steps to reduce burnout among health care professionals? Comment on this post below. Note: to post a comment you must be logged in. Register or log in.

Paula Davis Laack, JD, MAPP, is a lawyer turned stress and resilience expert who works with healthcare organizations and individuals to implement strategies that reduce burnout and build stress resilience. You can connect with Paula at www.pauladavislaack.com.

Ricardo J. Aguirre, MD, physician anesthesiologist, South West Healthcare System

What are the biggest patient safety challenges you face as an anesthesiologist?

“Establishing and maintaining a culture of safety, at both the local and institutional level, is one

of the biggest patient safety challenges I face as a physician anesthesiologist. In reviewing sentinel events or even near-miss events, several of the top 10 occur in the perioperative environment. However, oftentimes the breakdown in the safety-net system occurs long before the patient reaches the operating room.”

When we read about anesthesia, it is referred to as one of the safest disciplines

in health care. What are your thoughts on this?

“One of the fundamental principles of providing safe anesthesia care is constant vigilance of the patient. We are taught this early on in our training and is the motto of our professional society. Vigilance, in conjunction with the technological advances that are available today in how we monitor our patients, has made anesthesiology one of the safest specialties in medicine. The feedback we receive from the various monitors is continuously integrated into our clinical assessment of the patient to help guide our medical decision making.

"As a result, physician anesthesiologists have made the medical care that is provided in hospitals safer. For example, in remote locations outside of the operating room where sedation is required for procedures, having an anesthesia care provider whose primary focus is on the care of the patent, provides the utmost protection that patients need and deserve. It allows the proceduralist to carry out the intervention while we keep the patient safe and comfortable, ensuring that the appropriate level of oxygenation, ventilation, and circulation is occurring.

"While it is well known that the safety of anesthesia has improved significantly over the last several decades, it is imperative to understand that anesthesia care is provided within systems—systems that are managed by humans, systems that are prone to error. Most often, it is a system malfunction that contributes to a mistake and subsequently to an unexpected outcome where patients are injured.”

"As a physician, I naturally placed the blame completely upon myself, but in reality, there was a series of missteps that occurred which contributed to the mistake."

—Ricardo Aguirre

Why did you choose to become a member of ASPPS?

“I became a lifetime member of ASPPS from the encouragement of an article in the Anesthesia Patient Safety Foundation’s newsletter. It is important for me to represent my specialty in this evolving field of medicine. Obtaining my professional certification in patient safety will enable me to broaden my knowledge base by learning the science behind patient safety, system issues, and human factors. It also holds me accountable to be a patient safety advocate in my professional practice and allows me to be a resource to my colleagues. The benefits of membership span from the vast educational resources available to the opportunities to collaborate and network with others who share a passion for patient safety.”

Could you tell us about the talk you are working on currently, The Anatomy of a Wrong-Sided Block?

“Several years into my professional practice in the community setting, I performed a wrong-sided block. Although the patient was not harmed, I was devastated, felt ashamed, and it really took a toll on me emotionally. This talk is a narrative on my experience, what I learned from it, the steps I took in disclosing the mistake to the patient, and the changes I made in my practice to prevent it from happening again. As a physician, I naturally placed the blame completely upon myself, but in reality, there was a series of missteps that occurred that contributed to the mistake. For example, at that time there was no pre-procedural consent form and the original schedule was incorrect, only to be changed moments before the surgery. Everyone, including myself, was in a hurry to get the case started on time and a proper procedure time-out was not done. Additionally, due to the culture of the environment, the OR technician was afraid of speaking out, even though he was sure it was the wrong side. My hope is that by sharing this experience, other practitioners will learn from my mistake, preventing it from happening to anyone else.”

In your opinion, how do you move forward to promote a culture of safety?

“As an individual, becoming a Certified Professional in Patient Safety is one way that I am promoting a culture of safety. Additionally, I believe that the stigma associated with medical errors must be removed. We have to acknowledge that we as humans are fallible, that medical errors will occur, and that we must take the necessary action to learn from those mistakes to prevent further harm. Lastly, we need to provide all members of the health care team with the appropriate feedback through interdisciplinary discussions, guidance on event debriefing and disclosure, and the sharing of personal stories. All of these are crucial to promoting a culture of safety.”

Burnout and lack of joy in work pose significant risks to health care organizations: 54% of US physicians are burned out and 33% of new nurses seek another job within one year. Burnout is a syndrome characterized by exhaustion, cynicism or depersonalization, and a sense of loss of personal effectiveness.This problem takes a personal toll on health care team members and also seriously impacts patient safety. The correlation between greater engagement and safer patient care is well documented.Reducing burnout results in improved quality, safety, and efficiency with lower turnover rates.

Joy in work occurs when all team members,

no matter their role, find meaning and

purpose in what they do.

Abundant evidence points to leadership behaviors that are an antidote to this significant problem. What leaders do makes a difference in reduced burnout, enhanced teamwork, lower turnover and safer care.

Health care leaders can reduce burnout and achieve safer care by focusing on selected cultural essentials. Through the same leadership actions, they can get a two-for-one outcome: just culture and joy in work. Leaders who ensure just culture behaviors will nurture environments for both safe care and enable colleagues to find joy and meaning in work.

Steps for leaders to integrate just culture and joy in work include:

Definitions of what are they are so everyone has a common understanding

Clear purpose statements of why they are important, which offers a clear focus

Actionsthat describe how we make gains in both

What

Just culture: a learning environment based on respect, trust, and fairness to achieve safe, highly reliable care.

In short, team members will know they will be treated respectfully, consistent with organizational values.

Joy in work: when all team members, no matter their role, find meaning and purpose in what they do. It results when colleagues have an intellectual, behavioral, and emotional connection to the organization’s mission (IHI in press).These environments are characterized by psychological safety. Psychological safety means an environment where all team members feel secure and capable of changing; they experience respectful interactions among all; are able to ask questions, seek feedback, admit mistakes, and propose ideas (Edmondson 2012).

Why

The primary way leaders embed culture is what they pay attention to and how they react to critical incidents (Schein 2004). Leaders are responsible for paying attention to and developing organizational behaviors that promote psychological safety, which enables both engagement and safety.

For instance, of seven drivers of team engagement identified, three are greatly enhanced by psychological safety (Edmondson 2012):

Organizational culture and values are evidenced in the behaviors that are consistent with a just and fair environment. How leaders react to critical incidents involving patient harm is a key behavior that reflects consistency –or lack of– with the intended organizational culture and values.

Social support and community at work are illustrated by respectful interactions among all team members no matter their role. Members feel they can speak up without fear of retribution; are supported by colleagues and leaders to do their best; and experience a sense of camaraderie in their daily work.

Workload and job demands show a balance between the work to be done and the time/resources available. Excessive workload is frequently due to ineffective systems that waste time, energy, and good will. These same ineffective systems lead to unsafe conditions.

How

As part of a well-designed leadership development process, leaders can ask the following organizational assessment questions to further advance their outcomes in safety and joy in work.

How well do we demonstrate just culture principles in every part of the organization?

What happens when an error occurs? What are leaders’ responses? Do the responses vary depending on level of harm or by what role was involved?

Are we as focused on much on system failures as we are on harm events?

Do we act daily to show that respecting others and treating them fairly is essential?

What fairness gaps do we have in our current actions?

Do we promote psychological safety through the following:

oBe accessible, visible and approachable to develop relationships with team members.

oAcknowledge the limits of current knowledge; frame the work as highly complex requiring all to contribute for great outcomes.

oBe willing to show fallibility and humility; acknowledge that we do not have all the answers and are learning.

oInvite participation.

oView failures as learning opportunities.

oUse direct, clear language.

oSet boundaries about what is acceptable behavior and hold others accountable for boundary violation(Edmondson 2012).

This list of what, why, and how is a means of strengthening the leadership journey towards safer care and an environment where joy and meaning thrive.

Medical residents working shifts of 24 hours or more make 36% more serious medical errors than those who are limited to working 16 consecutive hours, according to a 2004 study published in the New England Journal of Medicine.

Even with patient and physician safety in jeopardy over sleep deprivation and fatigue, there’s still much debate over reducing trainees’ hours. Some of the objection to duty hour limits comes from the idea that trainees need to work extra hours in order to gain clinical experience and that shorter shifts may cause harm due to the increased handoffs required.

To Christopher P. Landrigan, MD, MPH, research director of the Inpatient Pediatrics Service at Boston Children’s Hospital, director of the Sleep and Patient Safety Program at Brigham and Women’s Hospital, and associate professor of pediatrics and medicine at Harvard Medical School, however, the misunderstanding of this key issue is the jumping off point to start discussion and change.

In a 2013 interview in PSNet, Dr. Landrigan said that “the trick is to implement changes in work hours in concert with concentrated efforts to improve the handoff process, teamwork, and infrastructure. Doing so can address fatigue-related errors without necessarily leading to a substantial increase in handoff errors. The net result can indeed be one where fatigue-related errors are reduced and handoff errors are not increased either.”

Dr. Landrigan has a wealth of experience on this topic and is the featured speaker for the National Patient Safety Foundation’s next Professional Learning Series Webcast, Sleep Deprivation, Health Care Providers, and Patient Safety, on February 27, 2017. He has led numerous landmark studies on the epidemiology of medical errors and adverse events, and interventions designed to reduce their incidence. His most important work has been focused on developing reliable patient safety measurement tools, and improving the organization of residency programs and academic medical centers. Dr. Landrigan’s work has contributed to national changes in resident work hour standards.

In 2011, the Accreditation Council for Graduate Medical Education (ACGME) created a set of requirements stating that duty periods of PGY-1 (Post Graduate Year One) residents must not exceed 16 hours in duration. Most recently, however, ACGME is in the midst of a re-review of the requirements with the intention of deciding whether or not to revert these requirements, allowing PGY-1 residents to take on 28-hour shifts like their more senior colleagues.

We know that when restrictions on shift hours are put in place, residents report that their quality of life improves and the rate of serious medical errors is reduced. We’ll discuss this and much more on the relationship between health care provider work hours, sleep deprivation, and patient safety. Please join us for this timely discussion.

What are the biggest patient safety challenges you face at the University of Texas Southwestern Medical Center?

“The greatest challenge I face in my role at UT Southwestern is understanding the diversity of services we offer on our campus. Like many other academic medical centers, we deliver an array of services with various requirements from a regulatory and accreditation perspective. Outpatient and ambulatory areas are a melting pot for this diversity, resulting in slightly different ways of doing things in clinics that are on the same floor, or even share the same waiting area, but fall under a different governance structure.

"While safety is a common thread in all of these areas, we need to ensure that a level of consistency exists in our practices. To address these challenges, a group within our organization, representing a wide variety of key stakeholders, spent six months creating a strategy document to build a comprehensive safety plan with a focus in the ambulatory and outpatient areas. While we recognize how different each department is, it is important for us to ensure that we are all connected and working collaboratively.”

"We need to have an openness of mind and heart that errors occur, despite our best intentions."

—Adrian White

Tell us why you chose to become a member of ASPPS?

“I wanted to become a member of an organization with a tried-and-tested history in patient safety. NPSF has its finger on the safety pulse, and the resources it provides helped me from a practical viewpoint in framing our outpatient safety plan.

"It also allows you the opportunity to build a support network of safety professionals around you. I have used the NPSF message boards to ask patient safety questions and I’ve had multiple people respond, many of whom lived through the same situation and have the bruises to show for it. Instead of reinventing the wheel, these colleagues have given me something to consider and adopt to my own situation.”

What made you interested in joining the patient safety field?

“The first stems back to my nurse training. One of my best friends through nursing school was involved with a medical error while we worked together in orthopedics. How everything was handled after the incident occurred really upset me, and our group. There was a lot of finger pointing and blame, when, in fact, there were multiple processes that weren’t followed. For weeks I wondered ‘where were the stop gaps to prevent us, mere students, from falling into traps.’ It was a positive outcome in the end, but the incident really stuck with me.

"Fast forward a few years and at 24 I became a nurse manager in Ireland who thought he knew everything. But I made a drastic medication error, too. The patient was fine in the end, but my actions could have killed him. This made me realize that an overdose of self-confidence will set you up for failure, and your world can come crumbling down at any moment with potentially disastrous consequences. These two personal experiences made me think: What is patient safety all about? Since then, the investigator in me is always asking ‘how’ and ‘why,’ and safety issues have plenty of answers to share.”

What keeps you up at night?

“When you talk with colleagues about a safety issue and they respond with: ‘That wouldn’t happen in my area’ or ‘Why would someone in their right mind do that?’, that apathy or arrogance worries me. We are all flawed individuals, and things will happen. We need to have an openness of mind and heart that errors occur, despite our best intentions.

"I also worry that people are afraid to speak up. When a safety event happens here at my institution, I want people to know that we should talk about it. I want them to hear someone say ‘You’ve done the right thing by reporting this issue. We just want to know what happened and to discuss ways to ensure that it won’t happen again.’ Having that openness and willingness to discuss these issues will make patients safer in the future.”

What is something unique about you?

“I am an immigrant. I came to the US from Ireland in 2008. My upbringing in Ireland and my training as a nurse in a very different health care system has helped me bring a diverse lens in reviewing issues I encounter working here in the US. Also, I have learned that my ‘brogue’ is a very powerful tool, and quite often my colleagues ask ‘How did you get away with saying that?’”

New journal seeks to disseminate results of pediatric quality and safety work

When the first medical journal was published in the United States, doctors were still debating the merits of bloodletting, anesthesia was an emerging concept, and the stethoscope had not yet been invented. By today’s standards, of course, medicine back then was still very primitive and physicians relied more on instinct in their practices than on collective knowledge.

In January of 1812, that began to change. That month, the first issue of the New England Journal of Medicine was published, and in its opening paragraph, editor Dr. John Warren called on doctors to be “directed by a knowledge of preceding discoveries.” Instead of practicing medicine as individuals, the publication encouraged doctors to document their experiences and share that information.

It was a milestone in American medicine. Publishing their experiences allowed physicians and researchers to accumulate knowledge, step-by-step, across a vast array of conditions. Soon, other journals were founded that focused on specific diseases and conditions. Now, more than two centuries later, we take another small but important step along that journey.

Last fall, I was privileged to help launch the journal Pediatric Quality and Safety. While most peer-reviewed medical journals since the early 19th century have focused on disease, this is the first to focus solely on improving the medical systems that care for our most precious resource: our infants and children. Quality improvement (QI) was once only a peripheral concern for many organizations, but the time has come to make it a priority in pediatrics.

Though QI science has been maturing over the past few decades, it became apparent to me, as chief medical officer at Nationwide Children’s Hospital, that the pediatric perspective is unique. The mechanisms and types of injuries and preventable harm that children suffer while being cared for in the hospital, such as surgical-site infections and adverse drug events, are often different from those seen in adult care.

In an effort to address those pediatric-specific issues, our team at Nationwide Children’s Hospital developed an initiative called Zero Hero. The idea was simple: we needed to not only lower the rate of preventable harm and injuries in the children we care for, we needed to strive for zero instances.

The idea caught on, and in 2009 all 8 children’s hospitals in Ohio joined together to form a collaborative called the Ohio Children’s Hospitals Solutions for Patient Safety. Together, we followed the lead of Dr. Warren, freely sharing information about our experiences and openly debating and establishing best practices. Within the first few years, using QI science methodology, we attained considerable success in lowering preventable harm rates.

So successful were we that the concept has gone national. Today, more than 100 children’s hospitals across the country have joined our initiative, working to eliminate 10 hospital-acquired conditions, including adverse drug events, catheter-associated urinary tract infections, central line–associated bloodstream infections, pressure ulcers, and ventilator-associated pneumonia, among others.

Since 2012, through May of 2016, the Solutions for Patient Safety Collaborative has saved 6,686 children from serious, preventable harm, which has led to an estimated savings of more than $121 million dollars in medical costs. That’s an average of saving more than 4 children from harm and more than $76,000 in costs every day, with a consistent upward trend each month.

We still have work to do, which is where this new journal will play a key role. As children’s hospitals everywhere strive to develop and deliver quality, evidence-based care, the journal will provide a perfect vehicle for collaboration. We will be able to collect and concentrate data and information from all over the world in one place, where it can be freely shared, easily disseminated, and rigorously debated.

It was this approach that proved so effective for Dr. Warren more than 200 years ago, and it’s time we dedicate the same focused efforts to safe and quality care for our children.

--------------------------------------------Pediatric Quality and Safety (PQS) is an international, peer-reviewed, open-access, online periodical that publishes results of quality improvement and patient safety initiatives that impact the lives of children. For details about submitting a manuscript visit the website.

What made you interested in joining the patient safety field?

“During my time as a hospitalist I became aware of the kinds of significant medical errors that can happen in a hospital. In one case of a wrong-patient error, an elderly woman was mistakenly given methadone through a series of systems lapses and ended up in a coma in the ICU. It was upsetting to hear of this error, but I also realized the potential for Health IT systems to protect patients from harm by keeping providers from making errors. This event really affected me, and further drove my interest to adapt our IT systems to reduce errors that could cause harm to patients.

“Given my interest in the field, when the time came for our hospital to name a patient safety officer, they approached me and I jumped at the opportunity to take on that role. There is more formal education now, but back then there were few opportunities for training in patient safety. I found my way to NPSF because it was the only patient safety organization with the focus I was looking for. I started attending and volunteering at NPSF conferences to learn as much as I could about patient safety. I’ve continued that learning in my position as chief patient safety officer and through my research into wrong-patient errors and Health IT safety. The luckiest thing in the world is to have your job not feel like a job, but be a true passion, and that’s how I feel about patient safety.”

"It will be a long journey fraught with speed bumps and wrong turns, but if we keep designing and implementing safer systems,

Health IT will become as reliable as an ATM dispensing cash."

—Jason Adelman

What are some ways we can use information technology to prevent medical errors?

“I believe that eventually Health IT will make health care significantly safer and more reliable. It will be a long journey fraught with speed bumps and wrong turns, but if we keep designing and implementing safer systems, Health IT will become as reliable as an ATM dispensing cash. I believe Health IT will ultimately prevent diagnostic errors, medication errors, and generally help make healthcare reliable and safe.

“Some of the research I’ve done over the past several years has demonstrated how technology can help reduce errors. For example, I’ve created a metric to quantify wrong patient errors by developing an IT tool that looks for when doctors place an order on a patient, cancels that same order, and then places the exact same order for another patient. We would run this report twice a day and find at least 15 to 20 instances of potential wrong-patient errors each day, and then call the doctors involved and ask them what happened. Most of the time these events were confirmed as errors. We were then able to test interventions to reduce wrong-patient errors by using this metric. (See Understanding and preventing wrong-patient electronic orders: a randomized controlled trial.)

“In fact, we used this system for measuring wrong-patient errors to demonstrate that hospitals who temporarily name newborns Babyboy or Babygirl significantly increase the risk of placing an order on the wrong baby in their NICUs. However, we were also able to demonstrate that if hospitals used more distinct temporary names that incorporates the mother’s first name, such as Wendysboy or Judysgirl, they can significantly reduce this risk. This research was only possible because we had a reliable measure of wrong-patient errors.” (See Use of Temporary Names for Newborns and Associated Risks.)

Why did you become a member of ASPPS?

“I am passionate about patient safety. I want to continually learn as well as to share my experiences in patient safety, with the hope to improve patient safety beyond the hospital where I work. Being a member of ASPPS is one of the ways I use to connect with people.

“I am currently the chief patient safety officer at Columbia University Medical Center at New York-Presbyterian Hospital. I got this job because several years ago their quality and safety leadership read my article on wrong-patient errors. They got in touch and asked how I put the system together and I gladly shared everything I knew. I wanted them to have all of the information I had, so they could help patients at their hospital. Because of this, when there was a change in leadership they thought of me. I believe that when it comes to patient safety, we should all share what we know so that each person involved in patient care can contribute to making care safer for everyone.”

What is something unique about you?

“I have four kids so there’s always activity in my house. I can see how distractions can lead to errors. In my case, right after dinner I often join my four kids in the living room to play a game. On occasion the children and I will leave food out in the kitchen, which is annoying to my wife. It’s not a life-threatening error, but we can all use a little help dealing with distractions and human errors.”

The National Patient Safety Foundation recommends that patients make sure that all of their doctors know about every medicine they are taking.

byMichael Kelleher, MD

The following is a true story that involved a close relative of mine. For the sake of argument, we’ll call him “Mr. K.”

Mr. K. underwent surgery for colon cancer, complicated by a prolonged recovery with poor appetite, bloating, and persistent abdominal discomfort. At the same time, he was undergoing treatment for rheumatoid arthritis. His arthritis specialist had prescribed prednisone tablets at 10mg daily. There was no communication, however, between the surgical and arthritis specialists. In addition, the primary care physician (PCP) had not yet received a rheumatology note listing the new prednisone medication.

"Specialists usually have no idea

who else is treating you unless you tell them."

Mr. K returned three times to the surgical office with his post-operative complaints. He was advised that infection was unlikely because he had no fever. But, Mr. K’s prednisone therapy was masking his fever and the signs of inflammation in his belly. After another week of misery at home, he took himself to the local emergency department where he was noted to have dangerously low blood pressure and a CT scan that showed a very large abdominal abscess.

This near-fatal delay in appropriate care was the result of poor communication among the patient's three treating physicians. This is, unfortunately, a common occurrence in our fragmented health care system. Although some large multispecialty group practices have electronic health records (EHRs) that are shared across all clinical offices, most private offices do not share a common EHR platform and do not communicate electronically with all the other clinicians who are treating you. In fact, specialists usually have no idea who else is treating you unless you tell them.

In this scenario, we can all agree that more than just one thing went wrong, but when it comes to medication, everyone involved in your care needs to be on the same page. The National Patient Safety Foundation, the Agency for Healthcare Research and Quality (AHRQ), and others recommend that patients make sure that all of their doctors know about every medicine they are taking. This includes prescription and over-the-counter medicines and dietary supplements.

Even if the medical office staff does not specifically ask for this information, provide it and ask that it be included in the specialist records. This can reduce the likelihood of an adverse event like what happened to Mr. K.

Other things patients can do to promote safe care:

Inform clinicians of all treatment plans

Take a minute to call your PCP’s office staff to inform them of any treatment plans proposed or implemented by other clinicians. In theory, the PCP will eventually receive a mailed letter from the specialist with that information, but this is not a guaranteed process, and may not happen for several weeks.

Update your electronic health records

Most of these EHRs include patient portals, which give patients online access to their primary care site. This is a convenient way to update your PCP’s office (without struggling to get through on the phone) regarding care that you have received elsewhere.

When it comes to communicating with your health care providers, never assume that they know what another clinician has ordered for you. Always share the details.

Michael Kelleher, MD, past member of the Mass Medical Society's Quality of Medical Practice Committee, has 34 years of experience as a physician and medical executive responsible for patient safety and quality of care in large group practices.

We had a lot on our to-do list this year. As you know from your own work, there’s no downtime when it comes to patient safety. There’s much more that can be done, but we’re excited to share a few moments from 2016 that we’re especially proud of.

As we move into 2017 and take a look at just a few (out of many) memorable NPSF patient safety achievements this year, we hope it will inspire and give you some ideas to keep moving forward in making health care safer for everyone.

February

NPSF began offering several complimentary Ask Me 3 resources in an effort to help in the promotion of health communication and to encourage patients to ask questions. Take a look at the materials.

March

We kicked off the United for Patient Safety Campaign and celebrated Patient Safety Awareness Week, designed to spark dialogue and promote action to improve the safety of the health care system for patients and the workforce. In conjunction with this week, we held a webcast entitled Safety Is a Public Health Issue with top leaders from the CDC, CMS, and AHRQ. Listen here.

April

NPSF President and CEO Dr. Tejal Gandhi was named to the Modern Healthcare magazine’s 2016 list of the 50 Most Influential Physician Executives and Leaders. Here's the list.

June

NPSF President and CEO Dr. Tejal Gandhi and COO and Senior Vice President Patricia McGaffigan collaborated on a piece published in STAT on how long shifts affect both patients and residents. In addition, we introduced the ASPPS Member Spotlight monthly series. Each month we interview one ASPPS member about their thoughts on patient safety to share with you all. If you missed any, find the series here.

July

August

The second edition of the NPSF Online Patient Safety Curriculum was released, which provides a history of the patient safety field, presents current best practices, and outlines strategies for overcoming barriers to safe care. We also rolled out our first annual Member Appreciation Month with promotions for American Society of Professionals in Patient Safety (ASPPS) members. Last but not least, NPSF President and CEO Dr. Tejal Gandhi, Bob Wachter, MD, NPSF Lucian Leape Institute member, and Gary Kaplan, MD, FACMPE, Chair,NPSF Board of Directorsmade the list of100 Most Influential People in Healthcare by Modern Healthcare magazine.

November

A perspective piece by NPSF President and CEO Dr. Tejal Gandhi was published in the New England Journal of Medicine on lessons learned from recent events at the National Institutes of Health Clinical Center. Also, in the spirit of giving thanks, we recognized your efforts with this video (at right).

December

By the end of 2016, we reached nearly 1,500 health professionals who now hold the Certified Professional in Patient Safety (CPPS) credential. Will you join them in the new year?

Caring for patients and for each other today unfortunately must also include understanding the potential harm to patients and staff safety associated with the sad reality of violence in our workplaces.

Many of us in health care have witnessed or experienced workplace violence firsthand. Workers in health care are five times more likely to be victims of nonfatal assaults or violent acts than the average worker in all other occupations, according to the Bureau of Labor Statistics. It is critical, therefore, for those in the health care community to receive key resources to help them prepare for and address, as well as hopefully prevent, violent situations from taking place.

The Joint Commission recently introduced
a virtual workforce violence resource center
to help health care organizations deal with
this very important problem.

Health care staff come to their employment settings each shift expecting to help patients. Few physicians, nurses, or other health professionals would anticipate having to deal with the increasing episodes of violence spilling over from our communities into our hospitals, ambulatory centers, and other health care locations. Indeed these incidences can hurt or kill patients, staff, and visitors. “Active shooter” situations have become another important component of emergency management preparedness.

What can health care staff and leaders do to help prevent violence and mitigate the impact? One thing is to seek out education about the issue and potential solutions. The Joint Commission recently introduced a virtual Workforce Violence Resource Center to help health care organizations deal with this very important problem. This portal, which is free and open to all, contains links to articles and research, “From the Field” case studies, and links to federal and state agencies that address workplace violence.

The high reliability concept of "mindfulness” is an apt description of the vigilance needed to notice anything unusual or something that just "feels wrong” as you go about patient care. That intuition, coupled with education on how to de-escalate crisis situations and limit damage, can save lives.

Does your organization have formal plans for addressing or preventing workplace violence? Comment on this post below. Note: to post a comment you must be logged in. Register or log in.

Ann Scott Blouin, PhD, RN, FACHE, is executive vice president, Customer Relations, at The Joint Commission. She serves on the National Patient Safety Foundation's Board of Directors and is a lifetime member of the American Society of Professionals in Patient Safety at NPSF. Contact her at ablouin@jointcommission.org.

Why did you join the ASPPS?

“I joined ASPPS to be part of a larger, multidisciplinary community of people who are passionate about improving patient safety. I wanted to build relationships with people who have the same interests. In addition to being part of a larger safety community, I wanted to join an organization that would help me stay informed about the most important patient safety topics, and I aspired to contribute to the advancement of patient safety initiatives.”

"We must teach the science of safety to our colleagues

and trainees and then foster their interest in the field."
—Sheri Herner

What are some of the unique challenges in the field of medication safety?

“The medication use process involves many steps including prescribing, verification, dispensing, administration, education, monitoring, and reconciliation. Because it is so complicated and touched by so many people, there are many chances for an error to occur.

I am concerned that most community pharmacies do not have easy access to important health information included in electronic medical records. Pharmacists need to know information about illnesses such as concomitant diseases. For example, if a pharmacist is dispensing a prescription for a medication that is eliminated by the kidneys, the pharmacist should have access to the patient’s most recent kidney function tests to check that the dose is appropriate. In addition, they need access to lab results and procedure results to determine if a drug therapy is appropriate for a patient.

To help with this, we need an interoperability policy—the ability of different information technology systems to communicate and exchange data— that considers the sharing of pertinent health information to pharmacists who are responsible for evaluating appropriateness of drug therapy for individuals.”

In your opinion, what’s the future of the patient safety field?

“The patient safety field will prosper through partnering with colleagues who are actively practicing in clinical roles. We must teach the science of safety to our colleagues and trainees and then foster their interest in the field. If we help clinicians make a difference in their work environment, they will be strong advocates in the future and in other venues, even without having the title of safety professional. Those partnerships are critical to moving patient safety initiatives forward.”

What is something most people don’t know about you?

“One of my favorite activities is to work with clay. I like the challenge of envisioning what I intend to create with a lump of clay and then making it happen. I continually analyze my pieces to learn from my mistakes, and I try to have the same learning attitude in my professional life.”

Burnout among health care professionals is on the rise, as is workplace violence in health care settings. Could efforts to reduce the overlapping organizational contributions to these problems be a strategy to prevention?

Michael Privitera, MS, MD, professor of psychiatry at University of Rochester School of Medicine and Dentistry, has long studied and written widely about this question and related issues. As medical director of the University of Rochester Medical Center Clinician Wellness Program and current chair of the Medical Society of the State of New York Task Force on Physician Stress and Burnout, he also sees the impact of burnout, bullying, and violence firsthand.

“Burnout affects the worker, other staff, the institution, and patients on a daily basis,” says Dr. Privitera. “We can no longer look at burnout as a problem for individual health professionals to solve on their own.”

Workplace violence, while not as common as burnout, includes not only physical harm, but also psychological and emotional harm from bullying, intimidation, or harassment.

Dr. Privitera has found that while the organizational contributors to burnout—such as time and production pressures, changes in technology, and regulatory requirements—are increasingly recognized, some of these same factors may also contribute to increased workplace violence in health care. Likewise, he suggests that some of the same efforts at reducing burnout may also help reduce workplace violence.

“The more we recognize and address overlapping root causes of burnout and workplace violence, the more effective and long lasting our interventions could be,” he says.

Dr. Privitera will speak on this topic at the next Professional Learning Series Webcast, The Overlap between Organizational Contributions to Burnout and Workplace Violence…Is There Overlap of Solutions? Wednesday, December 7, 2:00-3:00 pm Eastern Time. Register at http://bit.ly/burnoutviolence

Have you ever heard someone say “I’m not getting the flu shot because it will give me the flu” or “Flu vaccines don’t prevent the flu”? If you have, you aren’t alone. These types of myths are perpetuated every time the flu season pays us a visit, so it’s time to re-visit the facts so you can make an informed decision about the flu shot.

The early results thus far during the 2015-2016 flu season show that 66.7% of health care personnel have received flu vaccination coverage, according to this survey by the Centers for Disease Control and Prevention (CDC). Our hope is that this number will continue to rise during the remainder of this flu season and beyond to create healthier communities. The position of the National Patient Safety Foundation is in support of mandatory influenza vaccination for health care workers.

Now, if we’re seeing that health care personnel vaccination isn’t at 100% yet, it’s even more important for everyone to know the facts about vaccinations. It’s possible that we all need a quick refresher, so here it is.

Myth 1: “I’m not getting the flu shot because it will give me the flu.”

The facts

The influenza vaccine cannot give anyone the flu. Vaccines are made with inactivated (i.e., not infectious) flu vaccine viruses or with no flu vaccine viruses at all (called recombinant influenza vaccine). In randomized, blinded studies, other than increased soreness/redness at the site of the vaccine, there was no difference in outcomes among those who received a flu vaccination and those who received a saline injection.

Myth 2: “Flu vaccines don’t prevent the flu.”

The facts

Recent studies show that vaccines reduce the risk of flu illness by about 50% to 60% among the overall population, according to the CDC. While the effectiveness of the flu vaccine can vary from year to year, vaccination reduces the risk of more serious flu outcomes and may make the illness milder in those who were vaccinated but still get sick.

If you are not concerned about getting the flu, think of others. Being able to protect people around you, including those who are more vulnerable to the illness such as babies and older people, may give you the extra motivation to get vaccinated. The first step to healthier communities is being informed, so if you’ve made it this far, consider yourself informed. Now spread the word and share this post.

Want to know more about flu vaccinations? Join the conversation on social media at #UnitedAgainstFlu and visit the American Hospital Association website.

What does patient safety mean to you?

“It means teamwork. Knowing that someone has your back and will help if things start to go off the rails is an incredibly powerful tool for error prevention. Another critical aspect of patient safety is taking a proactive approach. Asking Where can things go wrong and how do I prevent it? and adopting the aviation philosophy which is What’s the worst thing that could happen and how can I prevent it? is another error prevention strategy we should strive for in health care.

"NPSF runs the most impressive

patient safety conference in the nation."
—Elizabeth Duthie

Why did you join the ASPPS?

“NPSF provides excellent educational opportunities. There’s literature alerts, convening of expert panels, and disseminating of cutting edge information. NPSF has really excellent networking possibilities and you can meet so many people at their conferences. Speaking of conferences, I have to say that NPSF runs the most impressive patient safety conference in the nation.”

What are some of the biggest challenges you’ll face as you start your new position as patient safety director at Montefiore Hospital?

“The biggest challenge that I have found is leveraging learning after an adverse event occurs. I get that we need short-term fixes for problems after harm occurs, but we can’t stop there. We need to clearly identify the underlying systems if we are to achieve sustainable safety gains.”

What keeps you up at night?

“What gives me a worried heart is the tremendous burden of suffering that comes from medical error— the horrible physical and emotional burden for patients, families, and clinicians. In the workplace it has a ripple effect. I have watched colleagues become frightened about their own practice after witnessing the trauma high-performing clinicians experience after a serious sentinel event. They realize if it can happen to him or her, it can happen to me. It just rocks everyone’s world. The drive to stop that harm and the subsequent suffering is what fuels my passion for creating safer systems.”

In your opinion, what’s the future of the patient safety field?

“We need to better understand how to build partnerships between providers, clinicians, patients, and families across the continuum of care. I believe the future is when everyone works together not to just deliver excellent care within the hospital but has a commitment to see that excellent care extended into the community.”

What is something most people don’t know about you?

“With the help of a retired comic, I performed stand-up comedy in one of my prior jobs. I would come up with jokes about work and perform 10-minute sets at the end of meetings to provide comic relief during the work day!”

According to the Centers for Disease Control and Prevention (CDC), each year, more than 2 million people in the United States get infections from germs that are resistant to antibiotics, and at least 23,000 of these people die as a result. The CDC considers antibiotic resistance to be among the most pressing threats to public health today, and the drive is on to increase education and awareness about the issue.

Antibiotic resistance happens when bacteria stop responding to the drugs intended to kill them. This happens over time, as bacteria adapt and change. Inappropriate use of antibiotics contributes to the problem, because when a strain of bacteria is weakened, but not killed, it can develop ways to survive, or resist, effects of antibiotics.

The CDC leads Get Smart About Antibiotics Week, November 14-20. In advance of the week, here are five ways health care practitioners, patients, and organizations can take action.

Collaborate. It is important for all members of the health care team to work together and with patients and families to reduce the inappropriate use of antibiotics. Pharmacists and infection control professionals can help advise clinicians on the best antibiotic to use in each case. Clinicians can help patients understand when antibiotics are needed and instruct in the safe use of antibiotics. Find resources for patients and for health professionals.

Stop the spread of bacterial infections. Practicing good hand hygiene consistently every time, with every patient, is the easiest way to reduce the spread of bacteria that cause infections. This applies to health professionals, but also to patients and family members. If you need a refresher course in handwashing, here’s how to do it right.

Prescribe correctly and adhere to prescribing instructions. Estimates suggest that more than half of the prescriptions for antibiotics written in the US each year are, in fact, not necessary. When a bacterial infection is present and antibiotics are the best choice, health care practitioners need to be careful to use an antibiotic that will be effective while causing the least risk of side effects. Clinicians can learn more about safe prescribing.

Patients need to understand the importance of taking antibiotics exactly as prescribed. Moreover, like all medicines, antibiotics come with risks that patients and families should recognize.

Practice antibiotic stewardship. By instituting an antibiotic stewardship program, health care practices and organizations can improve individual patient outcomes, reduce the burden of antibiotic resistance, and reduce health care costs. The CDC has tools to help organizations get started on antibiotic stewardship.

Share what you learn. Used appropriately, antibiotics save lives and allow for advanced treatment of disease. Yet, according to materials from the CDC, if antibiotic resistance continues unabated, “we risk turning back the clock to a world where simple infections could kill people as they did a century ago.” The World Health Organization and others recognize this as a global threat. Spread the word to your professional colleagues, neighbors, friends, and in your community.

In January of 2014, Marian Hoy, then 66 years old, became ill with what she thought might be the flu. “I felt bad for three days,” she recalls. “There were red flags that it wasn’t just the flu, but I didn’t recognize them.”

A former Dallas police officer and police trainer, Ms. Hoy lives in a small town outside of Austin, Texas. Her illness led her to become so disoriented that she called the town’s chief of police and asked him to bring her a soft drink. “I know the police chief,” she says, “but I never would have called him for that had I not been suffering confusion.”

When she realized the trouble she was in, she called the EMTs and was taken in the middle of the night to the hospital that she chose, Seton Southwest, part of Ascension Healthcare. Doctors there discovered that scar tissue from a long-ago surgery had surrounded Ms. Hoy’s small intestine and stopped her system. She underwent surgery to repair the problem, and in the days afterward she experienced complications that included sepsis and pneumonia.

“Everything was going south” for a time, she recalls now. “I would say to the doctor, ‘am I in danger?’ because I couldn’t say the words, ‘am I going to die?’ And he would say, ‘No, Ms. Hoy, you are not in danger.’

“In other words," she says, "he thoughtfully used my own words, so as not to frighten me.”

If you’ve read this far you are probably thinking, “Wasn’t this supposed to be a good news story?” Indeed, Marian Hoy spent three weeks in the hospital, and she recovered very well. But that’s not the only good news. When she tells her story, it’s all about her experience of care.

“They treated me like I was the only patient they had,” she says. “They gave me very individual care. When I called for a nurse, they were there in minutes. My doctors, surgeons, interns—everybody knew my labs over the 24-hour period, but they came to my bedside to talk to me to see if I could put together a declarative sentence and understand their questions, something I was unable to do when I was admitted. And they spoke to me with language I could understand.”

Patient Experience Matters

Patient experience of carehas been defined as “the sum of all interactions, shaped by an organization’s culture, that influence patient perceptions across the continuum of care.” A 2013 study found “patient experience is positively associated with clinical effectiveness and patient safety,” and supports the use of patient experience as a measure of quality.

Ms. Hoy’s experience puts a face to that research. Grateful for the care she had received, she wrote a letter of thanks. She was subsequently recruited to join Ascension’s system-wide Patient and Family Engagement Steering Committee. Through her work with Ascension, Ms. Hoy became aware of the NPSF Patient Safety Congress and was awarded a patient scholarship to attend the 2016 meeting.

“When I went to Arizona for the NPSF Congress, I had no idea what to expect,” she says now. “I was extremely naïve about safety in hospitals. I don’t know that a lot of patients understand the gravity of patient safety issues. The lightbulbs just went off.”

As a former law enforcement officer, Ms. Hoy was particularly interested in issues discussed during a breakout session on workplace violence in health care, which is on the rise. “Until we include an in-depth discussion of how today’s violence can and does impact the hospital setting, I don’t think we’ve completed the conversation on safety,” she says.

Today, Ms. Hoy serves on three patient advisory boards within the Ascension system. She is intent on sharing her experience because, “they saved my life, and there is no way one can repay that debt.”

She wants people to know about it. But she is also adamant about urging others to speak up and bring an advocate with them if they can when they visit the doctor or hospital.

“Participate in your own illness, ask questions,” she says. “If your doctor doesn’t want to answer questions, find another doctor. This a conversation about your health.”

Why did you join the ASPPS?

“ASPPS helps me to approach my work in a more meaningful way. I often feel like a lone ranger in my field because there’s not that many of us, but the verbiage that is consistent with ASPPS gets the attention of the stakeholders, helps me to be able to tell my story better and to obtain resources for my department. The focus on patient safety and caregiver safety makes me realize what a great organization NPSF is. I felt as though this was an organization I had to be involved with because it is impacting patient safety on a global level.”

What does patient safety mean to you?

“It means having the correct systems and processes in place that make delivering care easy and safe on a regular basis. Care should be just as safe at 8:00 am on a Monday as it is on a Saturday at 2:00 am. I believe that having correct systems in place facilitate great care.”

What keeps you up at night?

“What keeps me up at night is that we have sicker and sicker patients in the hospital and coming up with the correct ways to meet all of their needs is difficult. I often wonder whether or not we can keep up with advances in technology. We can keep patients alive for longer than we ever have before, but that puts them at risk for all kinds of infections and other issues. It bothers me that we have advanced so far in medicine with extending how long we live, but we haven’t been able to ward off all of the secondary issues that are associated with it.”

In your opinion, what is the future of patient safety?

“The patient safety field needs to continue growing by really reaching out to different disciplines to join the organization, raising awareness of patient safety organizations, and getting more people on board so they aren’t operating in silos. Every specialist has something to do with patient safety. I feel very hopeful and renewed to understand that there’s this much work going on in improvement of patient safety. We are getting there.

I want to be in a place where doctors and other providers can talk to families about realistic expectations as far as their care. When you have crucial conversations with the families, families often open up. We don’t always see that in our health care colleagues, but I think patients and families would like to know the true prognosis because that would help with their decisions. For example, when someone asks me what I feel about the prognosis, I try to be open and compassionate, but I don’t mislead them. I think people appreciate that”

What’s something most people don’t know about you?

“I make puppets! I use items that people have thrown away to make gigantic puppets used in the plays that my husband writes.”

A recent survey conducted by the National Patient Safety Foundation showed gaps in health professionals’ knowledge regarding use of opioid painkillers. Only two-thirds of respondents were familiar with the Joint Commission Sentinel Event Alert on the Safe Use of Opioids in Hospitals, for example, and only 14% were familiar with the National Action Plan for Adverse Drug Event Prevention.

It may come as no surprise, then, that one of the most well-attended breakout sessions at the NPSF Patient Safety Congress in May focused on “DEA Drug Trends.” Thomas Prevoznik, liaison unit chief for the U.S. Drug Enforcement Administration, addressed some of the current questions health professionals have about what they can do to mitigate unintended harm from opioids.

At the NPSF Congress, attendees were most interested in learning about proper disposal of unused or unwanted pharmaceuticals and how the DEA and health care professionals can work together to combat the opioid epidemic to ensure public health and safety.

The DEA is in the process of conducting Pharmacy Diversion Awareness Conferences at the state level to educate health professionals about tactics they can use to minimize unintended outcomes. These events include speakers from the state’s pharmacy board, the police, the Department of Health and Human Services, and the DEA.

Thomas Prevoznik speaking at the 2016

NPSF Patient Safety Congress

Mr. Prevoznik says the events offer an opportunity to provide practical tactics to pharmacists and clinicians, for example:

Asking patients if they have a place to keep the prescription opioid painkillers under lock and key.

Asking clinicians to be more aware of the opioid epidemic and more conscious of the unintended effects of overprescribing.

Disposing of unused medications is another effort under way. Twice each year, the DEA, in collaboration with state and local law enforcement, sponsors National Prescription Drug Take-Back Day, an opportunity for people to clean out their medicine cabinets and safely dispose of unused medication. The last event was held in late April of this year, yielding almost 900,000 pounds of drugs—the highest amount collected since these events began in 2010.

“People are getting the message that they don’t need to save that just-in-case bottle,” Mr. Prevoznik says. “It’s better to get rid of it.”

Imagine it is 2046. What changes will have taken place to improve the safety of patients and the health care workforce? What would you like to see happen over the next 30 years—and what are you willing to do to make it a reality?

Those were among the questions posed to attendees of the 9th annual NPSF Lucian Leape Institute Forum & Keynote Dinner held in Boston on September 15. Dana Siegal, RN, CPHRM, CPPS, director of patient safety services, CRICO Strategies, led an afternoon session punctuated by skits illustrating one dramatic change in health care culture over the years: the move to tobacco-free health care organizations.

Ms. Siegal recounted how, 30 years ago when she was a new nurse, smoking in hospitals was not uncommon among doctors, nurses, and even patients (unless on oxygen, of course!). Slowly, things began to change; smoking was confined to the “back room,” then to the outdoors. And finally, not all that long ago, tobacco was largely banned from the grounds of most hospitals, including parking lots.

What does smoking have to do with patient safety? The point Ms. Siegal hit upon is that culture change does not happen overnight. It takes time, sometimes a very long time, for norms and attitudes to spread throughout an organization, a community, a region, an industry, and in this case, across the country. She invited attendees to share their wishes for what health care and patient safety would look like in 30 years.

Here are just a few:

Can you believe in 2016 that hospitals are one of the most dangerous places to work in the US? (For employees) #NPSFLLI9

Looking Forward: New Models of Safety and Risk

Prof. Charles Vincent provided an overview of new models
of assessing risk and promoting safety in health care.

Currently Emeritus Professor, Clinical Safety Research, at Imperial College, London, Prof. Vincent has an extensive background in research on the causes of harm to patients, consequences for patients and staff, and methods of improving the safety of health care. His most recent book, Safer Healthcare: Strategies for the Real World (co-authored with René Amalberti) is available at no charge as an e-book (download at http://www.springer.com/it/book/9783319255576).

Prof. Vincent’s talk centered on the question of whether it is possible to develop a framework or menu of interventions around patient safety, rather than addressing issues by project or outcome. He noted the correlation to a recent NPSF report calling for an overarching shift from piecemeal approaches to total systems safety.

Prof. Vincent hypothesizes that a framework of strategies and interventions could be applicable across all settings (hospital, home, primary care) and across all levels of care (frontline, organizational, regulatory, and patient self-care). He outlined three models of safety:

Avoiding risk (ultra-safe): Examples from outside of health care include the airline industry. This model is characterized by a tough regulatory system and the need to avoid risk as much as possible.

Managing risk (high reliability): Risk is not sought out, but is inherent in the work, for example, firefighting. This model is marked by group intelligence and adaptation, with training and safety focused on flexibility and personal resilience being a key component.

Embracing risk (ultra-adaptive): An apt example here is deep-sea fishing, where risk is the essence of the profession. Working conditions are unstable and unpredictable.

While some areas of health care may fall into the ultra-safe category, where the goal is to avoid risk altogether, other areas may be categorized by the need to manage or mitigate risk.

Another example Prof. Vincent offered to illustrate the point is home dialysis. Patients and families performing dialysis in the home are trained in how to do it and in safety practices. But they are also schooled in what to do if something goes wrong, which Prof. Vincent said works better than drilling in to people that they have to do things perfectly every time.

“Absolute safety is not the aim,” he said. “We know it is never going to be safe; we need to manage the risk.”

Looking Back to Make Advances

Dr. Pamela Cipriano, president of the American Nurses
Association, discussed the need to assess the impact and
success of patient safety initiatives.

During the evening keynote address, Pamela Cipriano, PhD, RN, NEA-BC, FAAN, president of the American Nurses Association, noted that those in attendance are already on board with the need to make patient safety the priority. “You’re all converted,” she said. “We can be zealots. The people who are missing haven’t gotten the message.”

Quoting Max DePree, Dr. Cipriano noted that, “When we talk about patient safety, the leader is the servant.” Leaders of health care organizations are the key to setting the bar for safety in their organizations, but not all health care leaders are aligned with the principles that are so important to patient safety.

Dr. Cipriano also cautioned that unintended consequences can result from aggressive agendas. “We don’t always go back and look at the impact” of initiatives, she said.

She offered the example of the practice of isolating patients with Methicillin-resistant Staphylococcus aureus (MRSA) and using contact precautions (gloves and gowns). For years, clinicians and regulators supported the practice of implementing contact precautions of patients found to have MRSA. This process was mandated in a number of states. In 2015, a study argued that the benefits of contact precautions had not been proven, no study had directly compared the effectiveness of contact precautions to standard precautions, even as we know that the use of contact precautions has deleterious effects (psychological and otherwise) on patients. As a result, some hospitals are now moving away from the use of contact precautions and isolation for patients with MRSA.

Excelling in patient safety requires that practices, protocols, and initiatives get reviewed and, if necessary, revised over time. Or, as Prof. Vincent notes in his book, patient safety is "a moving target." “In a very real sense innovation and improving standards create new forms of harm in that there are new ways the healthcare system can fail patients,” he writes.

The most frequently referenced survey of health literacy in the U.S., the National Assessment of Adult Literacy (NAAL), found that only 12% of English-speaking adults are at the “proficient” level of health literacy. That leaves an awful lot of us who sometimes struggle with common tasks such as reading and following directions for the use of prescription medications or adhering to other care plan activities.

Health literacy has been defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” Proficiency is dependent on much more than the ability or read. The ability to use numbers, communication and reasoning skills, and cultural backgrounds all contribute to health literacy.

October is Health Literacy Month, so there is no better time to learn more about the problem of low health literacy and what you can do to be part of the solution.

An Equal Opportunity Problem

The NAAL found that health literacy is an issue for all racial and ethnic groups. Although health literacy increases with higher levels of education, 44% of those with a high school education are at basic or below basic levels. Among age groups, those 65 years of age or older are more likely to have health literacy skills at the basic or below basic levels.

The National Action Plan to Improve Health Literacy (2010) lays out goals for improvement. Among them, a call to the health care system and health practitioners to simplify complex language and present information in ways that make it more easily understandable.

Lea Anne Gardner, PhD, RN,
senior patient safety analyst
at the Pennsylvania Patient
Safety Authority, will discuss
health literacy in the NPSF
Professional Learning Series
Webcast on September 27.

Recently, the Pennsylvania Patient Safety Authority has been involved in a statewide initiative to provide health care practitioners with strategies they can use to help their patients understand and be involved in their care. Researchers at the Authority searched the Pennsylvania Patient Safety Reporting System and found 265 event reports over a 10-year period that were potentially related to low health literacy.

The most frequent outcomes of patients misunderstanding instructions or information were delayed or cancelled procedures, surgeries, treatments, or tests; or patients leaving without being seen, according to an advisory issued by the Authority in June.

The advisory also discusses ways that practitioners can recognize low health literacy and some of the tools and strategies they can use to communicate more effectively. Among the recommendations are using teach-back methods, plain language, and open-ended inquiry, such as “What questions do you have?” rather than “Do you have any questions?”

Another method included in the advisory is the Ask Me 3 program run by NPSF. A cornerstone of health literacy communications, the Ask Me 3 program is designed to facilitate open dialog between patients and providers by encouraging patients to ask three key questions when receiving care:

What is my main problem?

What do I need to do?

Why is it important for me to do this?

During Health Literacy Month and beyond, NPSF urges organizations to adopt these strategies to communicate more effectively with patients. Ask Me 3 is easy to implement and materials and guidance information can be downloaded on this website.

Take Action

Even with a recognition of the problem, it takes time for clinicians and organizations to retool the information and methods they use to communicate with patients. Resources are available to help.

A wealth of information about health literacy, including links to state organizations, is available via the Centers for Disease Control and Prevention. Visit www.cdc.gov/healthliteracy/, and use Health Literacy Month as an opportunity to educate yourself, your colleagues, your family, or your patients.

What does patient safety mean to you?

“I echo most in our profession that patient safety means having the patient receive the right treatment, at the right time, for the right reasons, and delivered without preventable harm. However, I also understand that without keeping our staff safe, healthy, engaged, and educated, we will not be able to truly accomplish patient safety.”

Why did you join the ASPPS? What does it mean to be a lifelong member?

“In 2011, I was given an incredible opportunity to join colleagues to help develop content for the Certified Professional in Patient Safety (CPPS) exam. When the first iteration of the exam was released, I was also part of the faculty for the first live preparatory course held at the NPSF Patient Safety Congress. It was through this work that I knew that I would always be committed to NPSF. What better way to show solidarity than to become a lifelong member.”

What keeps you up at night?

“I worry about the staff and their well-being in our fast paced environment. Our staff is so compassionate and hardworking, but I worry about burnout for our interprofessional staff, residents, and attending physicians. I worry about challenges with electronic medical records where it no longer shows us a longitudinal patient story, but is a series of reports that one has to know how to access. For example, our nursing colleagues couldn’t see some of the fields that providers had complete and vice versa, so we needed to create an interdisciplinary note that all could see. I could go on forever what keeps me up at night, but I guess that is part of the makeup of a patient safety professional.”

What is the future of patient safety?

“I think the future of patient safety lies within transitions of care from the hospital to long-term care to the home. Anytime we have a patient handoff, whether it is within the hospital setting or beyond, we risk losing critical pieces of the patient story. I look forward to the true one patient-one record. Patient safety challenges in the ambulatory setting include missed, delayed, or incorrect diagnoses. This should continue to be an area of focus for all of us.”

What’s something most people don’t know about you?

“I spent 12 years studying mixed martial arts. It gave me peace and an exhausted body when my mind was full of worry!”

As part of ASPPS Member Appreciation Month this August, we asked the ASPPS community to tell us what patient safety means to them. Thanks to everyone who participated!

We received many great responses and chose a few that resonated with us to share with you.

What does patient safety mean to you?

“Patient Safety means that every patient who comes to our organization is given care that surpasses their expectations and is given in a way that prevents avoidable harm to them. It means that the processes that our staff and providers are following are modeled after best practices and are evidenced-based and that our staff feels safe to speak up and report issues that are occurring to prevent further issues. Patient safety is about being mindful of an expectation that mistakes can happen and consistently looking to prevent them. Patient safety is about putting our patients first! Patient safety means that I am doing what can be done to provide the right care at the right time, every time.”

—Sandy Dimas, Accreditation & Patient Safety Manager

Keck Medical Center of USC, California

“Patient safety means doing the right thing for the right reasonwhen no one else is looking!”

—Diane Schloeder, BSN, director

Scripps Mercy Hospital, California

“I am a public health professor who loves to awaken the next generation of patient safety champions through my courses. Our students take a long, hard look at the patient safety movement over the last two decades, study improvement successes, and consider the challenges ahead. And then we commit to making personal and professional efforts to advance patient safety through safety culture, leadership, technology, staff training, and patient education. Patient safety and quality professionals can support providers and institutions in efforts to achieve greater transparency. We also have the equally important role of engaging and educating consumers about patient safety. There can be no competing over patient safety. For when one of us, whether patient, family, professional, or institution, loses, we all lose. The solutions lie in our open and honest discoveries and shared goals of safe care, patient engagement, and meaningful work.”

“Patient safety is the building block to creating the vision of a highly reliably community, free from harm

in which everyone is physically and emotionally healthy.”

—Bryan Buckley, MPH, Project Manager, Performance Improvement

MHA Keystone Center, Michigan

“Patient safety means commitment of leadership in developing a just culture in the organization. Leadership should take all steps to reach to zero harm. Leaders should develop ways to achieve happiness and trust among all staff. Happy staff will work more efficiently and create a healthy environment which more safe. This is the reason that our government is the first in the world that have appointed a Minister of Happiness. I believe that all leaders' vision and strategies should start and end with safety and quality.”

There are many medical situations where more care and more testing does not translate to better care. The American Board of Internal Medicine (ABIM) and its partners, through the Choosing Wisely campaign, have compiled lists of tests and procedures that should be carefully considered.

Let’s take a look at how excessive testing and procedures can do more harm than good. This is the case of a real patient. We’ll call her “Mrs. B.”

Physicians often perform tests

of marginal value because of
patient demands.

Mrs. B’s Multiple Procedures

Mrs. B had been experiencing upper abdominal pain after meals. Her ultrasound test revealed gallstones were the cause. One of her liver tests, a gamma-glutamyl transpeptidase(GGTP), was also mildly abnormal, so her husband, who had been a critical care nurse, pressed the gastroenterologist to proceed with more testing. Her husband wanted to exclude the possibility of her bile duct being blocked by a gallstone.

The physician performed an endoscopy test called an ERCP as a prelude to surgery. That ERCP test revealed no abnormality, but within an hour after the procedure, Mrs. B begin having severe abdominal pain and very low blood pressure. Her daughter alerted the nursing staff, and Mrs. B was rushed to the operating room for repair of a ruptured loop of bowel, a known complication of ERCP, which extended her recovery by three months and caused several postoperative infections.

What Went Wrong?

First, the ERCP test was not necessary in this case. It caused a serious complication, which was preventable. The mildly elevated GGTP test by itself did not suggest blockage of the bile duct with a stone, and is not recognized by experts as an indication for ERCP testing.

Secondly, physicians often perform tests of marginal value because of patient demands, to reduce their perceived risk of a malpractice lawsuit. Neither patient nor physician are well-served by such misguided testing.

Finally, over-testing can have negative results for patients. Screening tests for healthy patients represent a special challenge for shared decision-making. It is imperative for clinicians to make sure that patients have a thorough understanding of the risks, benefits, and limitations of such testing.

Low-Value Testing

Consumer Reports has worked with the Choosing Wisely campaign to create patient-friendly summaries of more than 50 medical tests and procedures that are of low value. Before agreeing to treatment, patients can look through evidence-based information on what may or may not be appropriate. There’s a wealth of information on procedures from colonoscopies to Lyme disease tests.

The campaign is meant to empower patients to start a conversation with medical staff regarding which treatments are appropriate or necessary. When it comes to medical procedures, always do your homework and speak honestly with your doctor about any concerns you have.

Michael Kelleher, MD, past member of the Massachusetts Medical Society's Quality of Medical Practice Committee, has 34 years of experience as a physician and medical executive responsible for patient safety and quality of care in large group practices.

Fairview Health Services and their collective commitment to a culture of excellence in their hospitals is what stood out to the National Patient Safety Foundation when awarding this year’s Stand Up for Patient Safety Management Award. This award is given each year in recognition of the successful implementation of an outstanding patient safety initiative that was led by, or created by, mid-level management.

Fairview Health Services, consisting of six hospitals within Minnesota, aimed to prevent errors in specimen management to make care safer for their patients. Fairview identified specimen mismanagement as a “never event” and thus started the complex process of reducing the risk of mishandling.

According to the Agency for Healthcare Research and Quality (AHRQ), mislabeling errors are one of the most common preanalytic errors in laboratories. Many initiatives were put in place, including Fairview’s use of specimen label printers which made a big difference in specimen management. As a result of system-wide changes, including standardizing processes of surgical debriefing, handoffs, and labeling, there was a 70% decrease in the risk of specimen mismanagement.

Here’s what Fairview Health Services had to say about this important work.

What were the biggest challenges involved in a project such as this?

“Our two biggest challenges were information technology issues, including getting various programs to talk to each other and making our electronic medical record more user-friendly, and standardizing processes. Initially, we assumed our processes varied widely from site to site, but after mapping out processes across our system, we learned we had more in common than we previously thought.”

What surprised you about the process, either in regard to the way the project team worked or in regard to something you learned about the processes that you did not already know?

“Learning that labels and specimens were labeled and logged by hand, which is not best practice, reinforced our drive to improve. We knew we could do better for our patients. On the plus side, our team became highly functional very quickly. We used multi-voting techniques to prioritize the work so that all voices were heard, not just those belonging to squeaky wheels.”

You mentioned that patients are often unaware of the life-altering consequences of error in specimen management. How do you explain the importance of specimen management to your friends or family (i.e., someone unfamiliar with this topic) and what it means for their safety?

“If a specimen—something we obtained from a biopsy—is lost, we may not be able to make a diagnosis in a speedy manner. We may need to repeat the biopsy. Furthermore, some specimens are so unique that they are irreplaceable. A lost specimen of that type may mean losing essential information about the patient’s health. It may not sound all that important, but proper specimen management is utterly essential to helping us drive a healthier future for our patients.”

What are some ways to successfully engage physicians in the problem-solving process?

“We know physicians appreciate seeing data that proves the need for change and demonstrates the likelihood that the change will result in improved patient outcomes. Also, like most employees, physicians want to be asked for their input and know that their contributions are valued and acted upon.”

What are two tips you would offer others undertaking similar projects that might help them succeed?

“First, system-wide changes require system-wide representation. In addition to the appropriate subject matter experts, you should also include people who provide support services, such as IT, Operations, Communications, and Human Resources. These team members help the group think of broader implications of a proposed change, and can often contribute to coming up with corresponding solutions.

Second, getting people to agree to serve on yet another committee or workgroup can be tough. Show participants you value their time by creating unusual, but effective meetings. Get people up and moving by breaking into small groups spread out across the room. Record ideas on flipcharts and draw process flow maps on white boards. Award small prizes for attending. Improving patient safety is serious work, but by engaging employees and physicians in different ways, we can often come up with better solutions.”

Could you talk in general about lessons learned from this process?

“It’s important to obtain the support of an executive sponsor—someone at the highest levels of leadership. This indicates to everyone involved that the project is a high priority and reinforces the urgency of successfully completing the change. Get IT involved in the project from the start and know who to turn to when you need to escalate concerns. Use a system team of stakeholders that is truly representative of all entities and divisions. Be aware of unintended consequences. When you change one part of a process, there may be unintended negative consequences. Be open to discovering, and correcting this. In fact, embracing a spirit of discovery can make all the difference for improving the health of our patients.”

Why did you join the ASPPS?

“I feel that the ASPPS provides a great balance of education, training, and networking for those who have a passion for making health care safe. I have found that the number of resources and blogs available online at NPSF are helpful, especially in my current position at ChenMed.”

What are some of the unique patient safety challenges in the ambulatory setting?

“On a personal note, my father has been hospitalized four times in the past year and has had numerous visits to his PCP, specialists, urgent care facilities, and the emergency room. I find that the common gap in most of these interactions has been inadequate or missing communication between treating physicians, other health care providers, and my parents.

With health care providers rendering care for the same patients at, and from, multiple locations, real-time communication and effective handoffs become a challenge. Not having information readily available adds to the complexity and makes the delivery of care inefficient, ineffective, and possibly untimely and unsafe. At least within the four walls of a hospital, you almost always have the luxury of real-time electronic or direct communication with providers who are working in close proximity, which is not always the case in the ambulatory setting.”

You’ve been a judge for the Baldrige National Performance Excellence Award Program. Has this experience influenced you in any way?

“The last three years as a national judge has been a great learning experience. I had the opportunity to review and discuss the applications of some very high performing organizations with a panel of experts having a wealth of experience and diversity of expertise. What has been very obvious is that health care organizations performing at a very high level have a few common traits: leadership committed to safety and quality, dedicated resources made available to accomplish identified goals, and a culture conducive for high performance.”

What keeps you up at night?

“Although the patient safety movement has garnered much needed attention over the past decade and a half, we remain largely focused on the acute care side. Even though there has been a significant shift of focus to prevention and management of care on the ambulatory side, there is much that can and needs to be done.”

What is something most people don’t know about you?

“My desire to become a physician came at the age of seven, during a summer vacation visit to my grandparents in rural India. One of their tenants was a physician who had the ‘magical touch’ of bringing people back to life without the aid of a hospital. What I learned much later was that he was ‘magically resuscitating’ villagers who were extremely dehydrated with a basic combination of fluids and antibiotics. Many years later I still marvel at the simplicity and power of health care at the bedside.”

“It means equipping clinicians with systems and processes that help them to avoid error, and keeping patients from suffering from injuries from the very place they sought out healing.”

You did pro-bono work as a law clerk at the Pennsylvania Health Law Project, which advocates for low-income patients. What are some patient safety issues facing this population?

“Many very young, often single parents, with severely disabled children, as well as very elderly patients, are desperately trying to navigate a very complex and disconnected health care system. Often these patients are seeing multiple health care providers at the same time, but each without any communication with one another, or awareness of what treatments the other had prescribed or recommended.

One young mother I worked with had a severely disabled child. She came to our office beside herself with guilt for not being able to afford all of the drugs her daughter had been prescribed. I’ll never forget her gratitude when, by fostering communication among her daughter’s multiple providers, we determined not only did she not need the additional drugs, but taking all of them together may very likely have killed her.”

Why did you join ASPPS?

“Through my work as an associate director of medical/health administration for the University of Florida Health Science Center since 2002, I witnessed the impact of increasing financial pressures. I started asking myself: how do we shift the focus to be on health care quality and patient safety first? In seeking to answer this question, I came to learn of ASPPS and welcomed the opportunity to be a part of an organization full of like-minded individuals, many of them clinicians, and with the same important focus on patient safety.

The goal of becoming a Certified Professional in Patient Safety was an opportunity to become much more knowledgeable in the actual how of patient safety by immersing myself in understanding the clinical side of health care operations and patient safety activities that help clinicians and patients alike in achieving higher quality health care.”

How does your law firm help clinicians and patients?

“My role at Dell Graham as a legal advocate and risk manager for clinicians and others in the health care industry is to proactively address, standardize, and simplify the business and regulatory side of health care so that they can give their 100% to providing high quality health care. The work I have the opportunity to be involved in now is the most fulfilling of my professional career.”

You said that clinicians are at risk due to a broken health care system. In your opinion, what improvements should be made to make the system better for everyone?

“Two things are crucial for improvement. The first is better coordination and communication among all the fragmented pieces. The second is developing and fostering a just culture within organizations where there is no finger-pointing, shaming, or disproportionate disciplinary actions. This is the key to an environment where every medical error becomes an opportunity to learn and improve upon the quality of health care within the system.”

]]>Wed, 29 Jun 2016 16:00:56 GMTEvidence As a Seed for Collaboration: Separating the Wheat from the Chaffhttps://www.npsf.org/members/blog_view.asp?id=1158873&post=251277
https://www.npsf.org/members/blog_view.asp?id=1158873&post=251277

I have been monitoring the patient safety literature for more than two decades now, first as the information project manager at the National Patient Safety Foundation, and for more than a decade as the development editor for AHRQ Patient Safety Network. As those in patient safety might attest and applaud, the evidence base has gotten more robust over the years, spurred by increased funding for research and public interest in the topic.

This expanding wealth of literature creates a challenge for organizations and individual practitioners. The unintended consequence of this explosion is that there is more wheat to sift through. The growing set of materials makes tracking useful evidence more cumbersome while in turn increasing the messiness of translating existing research results into actions that make sense and conclusions that are credible. We know that just because it’s science doesn’t necessarily mean it’s good science. We know that just because it’s published, identified, and shared within an organization, community, or team that evidence derived from science is not necessarily applied or able to be translated for use on the front line.(Zipperer 2016)

While somewhat editorial in nature,
Dr. Shojania’s presentation brought nuance
to seeing how the evidence exploring these areas
can play a part in our understanding of them.

There are tools out there to help with creating awareness of materials, such as AHRQ Patient Safety Net and the NPSF Current Awareness subscription service. However, not only should organizations have individuals trained to monitor these resources, also the search for particular evidence needs to address local gaps in understanding and effectively disseminate the literature to decision makers. Someone in the organization should navigate this output in order to help their clinicians and executives apply it if it is going to enrich the design of interventions and implementation of programs and contribute to enhancing the reliability of their patient safety work.

We could all use someone like Dr. Kaveh Shojania to help translate what is written to help create actionable knowledge in health care.

Dr. Shojania—with whom I work in my role at AHRQ Patient Safety Network, as he is on the editorial team—has for three consecutive NPSF Congresses provided a thoughtful and provocative analysis of key articles and the trends they indicate for conference attendees. This year’s session, entitled “Hot Topics in Patient Safety: Selected Papers Advancing the Field in the Past Year,” did not disappoint. Dr. Shojania covered literature on 6 important topics:

Diagnostic errors

Rudeness’ impact on team performance

Trends in adverse events over time

Incident reporting

Fall prevention

Reducing high-risk prescribing in primary care, with a focus on the current opioid abuse/misuse epidemic in the US

These themes should be no surprise to those in the patient safety community. While somewhat editorial in nature, Dr. Shojania’s presentation brought nuance to seeing how the evidence exploring these areas can play a part in our understanding of them. While some analysis of research design was applied, and the value of results was discussed, Dr. Shojania’s insights should enhance our ability to be more critical of what is published and by whom.

Imagine the opportunity that the sort of dialogue generated by this type of expert assessment could provide in an organization. The exercise could be brought to our care environments as more than a social or intellectually opportunity. If positioned as a patient safety improvement tactic, it could serve a more impactful role.

Dr. Shojania was challenged by an attendee, and his response provided thoughtful seeds for all of us who seek to partner to “plant” evidence-based solutions in the patient safety community garden. Imagine the learning and collaboration that could be generated in organizations if teams had these types of conversations on a regular basis, with accountability assigned to do something with the issues raised. Could the dialogues support increasing the transparency around sharing of ideas, forming of shared mental models, leveling of hierarchy, and engaging of individuals to form multidisciplinary teams to do research to reflect the frontline needs of improvers? Could be.

What tools, techniques, and team members do you use to identify, analyze, and infuse the most relevant literature to innovate and anchor patient safety efforts throughout your organization? Comment on this post below. Note: to post a comment you must be logged in. Register or log in.

Lorri Zipperer, MA, is the principal at Zipperer Project Management in Albuquerque, NM, specializing in patient safety and knowledge management efforts and bringing multidisciplinary teams together to envision, design, and implement knowledge sharing initiatives. Her latest collaboration was with The Risk Authority Stanford as a co-editor and contributing author of their 2016 publication Inside Looking Up. Contact her at Lorri@zpm1.com.

Tell us why you chose to get into the field of nursing.

“I used to ride horses all the time and on one particular day when I was 22, my horse and I had an argument. He jumped and I was thrown 30 feet up into the air. When the ambulance arrived, I was in a coma. I came out of it nine days later, but was completely paralyzed, and so I thought my life was over. In the hospital, the nurses were fabulous and their positivity was so important to my recovery. Because of that, I wanted to be a nurse and facilitate patients' healing.”

What brought you to join the ASPPS?

“When I saw what the ASPPS does for patient safety, it really spoke to me. ASPPS allows people to become proactively involved in patient safety. This is necessary as we have a medical system that results in too many medical errors. I feel membership is the first step towards involvement and making a difference for reducing their occurrence. Through patient safety involvement we provide better outcomes for our patients, which, I believe, in turn improves our job satisfaction.”

In your opinion, how do you move forward to promote a culture of safety?

“Awareness promotes safety. Awareness of your own self, of your actions, as well as an awareness of the patient, and their response to care matters. As a nurse, I feel that if the staff doesn’t take care of themselves, along with the support of hospital management, we will not have the where-with-all to take care of our patients. I love being part of a team culture where I can stand up and say, I don’t understand or I need help and receive the assistance that I need so I can support my patients.”

What is an example of something you (or anyone) can do to keep safety standards high?

“Two things:

Listen to the patient. Every body is different. You have to listen because a patient is an expert in his or her own body. If a patient is telling you something is off, perk up your ears and poke around to see if you can find out what the problem may be.

Take care of yourself. If you are well rested and alert, you can be your best possible self and the best possible nurse for your patients.”

In 2012, I left a pile of paperwork on my desk convinced that I would complete it later that afternoon when I returned from my first colonoscopy. It never occurred to me that morning that my colon would be perforated, that my insistence that something had gone wrong during the procedure would be ignored, and that I would require emergency surgery to resect my colon. I did not imagine that I would wake up in an intensive care unit and face a series of complications and mistakes that would change my body and life forever.

I did not imagine that I would
wake up in an intensive care unit
and face a series of complications
and mistakesthat would change
my body and life forever.

If you or a loved has one experienced a medical accident or an unexpected outcome from a medical procedure or hospitalization, perhaps this sort of nightmare sounds familiar. You know the surreal feeling of losing control of your health, of being engaged in battle to regain your physical and mental equilibrium while desperately attempting to find your way back to some semblance of a quality life.

I have worked in and around health care for 30 years, but was unable to prevent three medical errors resulting from a routine procedure. Ultimately, I survived and created a new way to flourish by actively taking control of my well-being. During my recovery, I wrote a book to help others navigate their health crises and reclaim their lives.

Here are the most important tips that I offer to anyone endeavoring to overcome medical challenges.

1. Advocate. One of the most difficult things to do when you are lying vulnerable in a hospital bed is to feel powerful, able, and strong. Each of us needs an advocate regardless of our physical condition or well being. Solicit a family member, friend, or case manager at the hospital to listen with you to your doctor’s recommendations and advocate on your behalf.

Be certain that everyone involved in your care knows your wishes about pain medication, additional tests and procedures, as well as what kind of heroic measures you sanction as a component of your care. If you have allergies especially to medications, review these with each new provider involved in your care.

Never assume that each doctor or nurse has thoroughly read your chart or is aware of your medical history. Health care providers are human and mistakes occur. Speak up to prevent additional complications whenever feasible.

2. Be Open. You may have a speedy and complete recovery after a medical accident or, like me, your body may only experience a partial restoration of function. Become an open-minded and educated consumer of medical and health services by inquiring about all of your treatment options.

Discuss any interest you have in exploring complementary, alternative medicine, and rehabilitation therapies with your doctors. Complementary and rehabilitation treatment providers tend to focus on function and prevention with the goal of maximizing your physical, emotional, spiritual, and behavioral health. Treatments such as acupuncture; cranial sacral therapy,; occupational, physical, and speech therapy; biofeedback; and mindfulness training are but a few of the possible adjunct services that you may find helpful, with regard to pain management, improved sleep, and learning to regain your capacity to manage your day-to-day responsibilities irrespective of whatever illnesses or chronic conditions may continue to persist.

3. Communicate. It is always the obvious that proves challenging and communication between doctor and patient is no exception. When you experience a medical crisis, your health care team will often be focused on the technical aspects of what transpired and what they need to do to stabilize your health. None of that changes your need or right to know what is happening to your body, what efforts are being made to rectify the medical issues that exist, and your treatment team’s thoughts about your prognosis. Trusting your providers is important, but blind trust benefits neither patient nor doctor.

Be certain to speak up and talk to your doctors about concerns that you have related to your health or healing. No matter how invested anyone is in your care, you are the only person who will eventually go home and live with your body, as well as the impact that these medical events will have on your health. If your medical team is not communicating the information that you need to hear, don’t be afraid to initiate that conversation to assure yourself that everyone is committed to your best possible recovery outcome.

Betsy M. Cohen is a Certified and Licensed Rehabilitation Counselor, a Certified Case Manager, and an American Board Certified Senior Disability Analyst specializing in the treatment of individuals who are affected by neurological and neuropsychiatric conditions and chronic illnesses. She is the author of Illness To Wellness: Reclaiming Your Life After A Medical Crisis. Ms. Cohen is also a member of the American Society of Professionals in Patient Safety (ASPPS) at NPSF.

Mark your calendars—and with good reason this time. In a world of National Chocolate Macaroon Day and Put a Pillow in Your Fridge Day, National Safety Month is something worth talking about.

The National Patient Safety Foundation (NPSF) this month, and every month, aims to empower patients to ask the critical medical questions that can make a difference in their care. The National Patient Safety Foundation's stance is that while patients and families can play a critical role in preventing medical errors and reducing harm, the responsibility for safe care lies primarily with the leaders of health care organizations and clinicians and staff who deliver care.

Even with the onus on health care practitioners to make care safe, here’s how you can take charge of your own safety:

1. Ask questions about the risks and benefits of recommendations until you understand the answers.

“The best advice I can give is to be your own advocate. Question, question, question until things are explained in a way you understand. A health care system that doesn't address your concerns is a risky one,” said Peter Pronovost, MD, PhD, director of Adult Critical-Care Medicine and a patient-safety researcher at the Johns Hopkins University School of Medicine in Baltimore in a recent article. If you aren’t sure what questions to ask, check out our Ask Me 3 program.

2. Don’t go alone to the hospital or to doctor visits.

Bring a sibling, spouse, friend, or neighbor— anyone you trust to be your ally.

According to a 2011 article in the American Family Physician journal, an advocate can:

Speak up for the patient who may not be expressing all of their medical concerns.

Help to keep track and remember all instructions.

Provide emotional support, even if they don’t interact directly with medical staff.

3. Always know why and how you take your medications, and their names.

In a 2015 study published in the Journal of the American Medical Association (JAMA), researchers found that from 1999 to 2012, the percentage of adults taking five or more prescription drugs doubled from 8% to 15%.

With prescription medications on the rise and with patients juggling multiple prescriptions, a two-way conversation around drug safety is needed.

Here’s what you should ask, according to a 2014 article from the Agency for Healthcare Research and Quality (AHRQ):

What is the medicine for?

How am I supposed to take it and for how long?

What side effects are likely? What do I do if they occur?

Is this medicine safe to take with other medicines or dietary supplements I am taking?

What food, drink, or activities should I avoid while taking this medicine?

4. Be sure you understand the plan of action for your care plan.

“Limited health literacy is a hidden epidemic. It can affect health status, health outcomes, health care use, and health costs,” according to 2008 article in The Permanente Journal. Oftentimes, medical information and terminology is complex, so if you don’t understand something, don’t hesitate to ask.

5. Say back to your clinicians in your own words what you think they have told you.

By practicing this step on a regular basis, it may help you remember the instructions after you leave and helps clinicians know if you’ve understood. For example, “Just so I understand, I need to take X medication, X times per day, for the next X days?”

6. Arrange to get any recommended lab tests done before a visit.

The advantage of getting lab tests completed before seeing a doctor is that the results can be discussed during the visit, instead of during a follow-up or having the results explained over the phone.

7. Determine who is in charge of your care.

Many health care settings are moving toward team-based care. If admitted into a teaching hospital, for example, you may find that multiple clinicians are involved in your care. There may be interns, a hospitalist, nurses, and doctors taking care of you at any given time. You can ask: “Who is the key person in charge of my care?”

For more information on patient safety for patients and families, visit our website.

Download this report of the Informed Patient Institute, done in conjunction with Consumer Reports, which evaluates what type of information is available to consumers on medical board websites nationwide.

Safety protocols are only effective if people follow them. Take hand hygiene, for example. While effective hand hygiene can reduce the spread of certain infections, the Centers for Disease Control and Prevention reports that, on average, health care professionals practice hand hygiene less than half the time that they should.

The difference between an inadvertent slip and an intentional disregard for a safety practice has been discussed before. So what is a health care worker to do if he or she sees a colleague behave in a way that undermines safety?

The Center for Patient and Professional Advocacy (CPPA) at Vanderbilt University Medical Center recently published results of a robust program to address colleague reports of unprofessional behavior. Lynn Webb, PhD, assistant dean for faculty development and lead author of the recent paper documenting the program, will be one of the speakers discussing this work at the NPSF Patient Safety Congress in Scottsdale later this month.

A Nonpunitive System of Change

"It’s really important to emphasize
that this is not a punitive process."
—Lynn Webb, PhD

The Vanderbilt CPPA team already had experience with patient reports of unprofessional behavior. The Vanderbilt Patient Advocacy Reporting System (PARS) is a method of collecting and aggregating patient complaints of physician behavior. According to Dr. Webb, PARS data have shown that 5% of physicians and advanced practice professionals (APPs) are associated with 35-40% of patient complaints about their medical professionals. The PARS method for graduated interventions has been adapted and put into place at more than 140 hospitals and medical groups nationwide.

Now, the principles behind the PARS program have been utilized to develop the Co-worker Observation Reporting SystemSM (CORS).

“The CORS program was established to provide systematic feedback to professionals associated with reports from co-workers about what appeared to be unsafe or disrespectful behavior,” Dr. Webb says. The system involves a method of capturing, reviewing, coding, and tracking data. Peer “messengers” are trained to share reports with professionals associated with the reports. The time between when a report is received by the system and the peer discussion is usually less than one week.

Dr. Webb emphasizes that the system is designed to address behavior that seems inconsistent with the Vanderbilt “Credo,” a statement of values shared by professionals and staff. “It’s important to share reports as soon as possible, giving professionals an opportunity to reflect on the issues raised in them,” says Dr. Webb.

In analyzing reports over a 3-year period, the CPPA team found that 3% of professionals were associated with 45% of reports. After the CORS intervention process was implemented, 70% of identified professionals have not been associated with another report.

At Vanderbilt, CPPA also compared physicians identified in the CORS program with those identified in the PARS process. “We found little overlap of professionals having high numbers of patient complaints and those having a pattern of coworker concerns,” says Dr. Webb.

The Vanderbilt CPPA team has compiled a “project bundle” for use by other organizations considering the implementation of such a system. The bundle includes elements of the program that organizations should have in place to help ensure successful implementation. These include strong leadership commitment, program champions, and policies that address expectations for professional conduct. Co-presenter Roger Dmochowski, MD, Vanderbilt’s executive medical director for quality, safety, and risk prevention, believes that success of the CORS program at Vanderbilt was linked to the early involvement of physician and nursing leaders in the development phase.

“It’s really important to emphasize that this is not a punitive process,” Dr. Webb says. “By having a colleague share an observation with another colleague, the intent is to be restorative and change unsafe or disrespectful behavior.”

Lynn Webb, PhD, and Roger Dmochowski, MD, will present details of the CORS program in Breakout Session 202 at the NPSF Patient Safety Congress. Find out more about the Congress agenda at www.npsf.org/congress.

Paul Epner, MBA, MEd, Co-Founder and Executive Vice President for the Society to Improve Diagnosis in Medicine, Chair of the Coalition to Improve Diagnosis, Immediate Past President for the Clinical Laboratory Management Association

Why patient safety?

“I was diagnosed with Crohn’s Disease at 16. I was subsequently hospitalized many times as an adult with some significant adverse events, giving me the drive to get involved with the patient engagement and safety movement. Coincidentally, I worked for 31 years in the Diagnostics Division of Abbott Laboratories working in the US, Japan, and China. When I left Abbott, it was to focus on issues of patient safety and quality of care, especially from a clinical laboratory focus as I believe the current narrow emphasis on in-lab costs totally misses the economic and patient benefits of a more care-centric clinical laboratory. That led me to diagnostic error, which led me to the Society to Improve Diagnosis of Medicine, and that led me to the National Patient Safety Foundation. It’s been a journey and I'm still on it.”

Why did you join the ASPPS?

“My activities following my retirement from Abbott reflect a shift from making a profit to making a difference. I saw what was happening at the ASPPS, I went through the programming, heard the patients’ stories, and I said, ‘This is great! I have to invest in this. This is an investment in me, it's an investment in healthcare, and it's worth doing.’”

"This is an investment in me, it's an investment in healthcare, and it's worth doing

—Paul Epner

In your opinion, what’s the future of the patient safety movement?

“This movement is critical to strengthening the quality and cost of care. I believe we have made great progress, but that people do recognize we're not there yet, and so the journey is still moving forward. I feel pretty good that with every step forward we will be saving lives and improving the experience for patients.”

Could you tell us about your work with diagnostic error at the Coalition to Improve Diagnosis?

“The Society to Improve Diagnosis in Medicine (SIDM) catalyzed the NAS report on Improving Diagnosis, but we recognized that we were too small to maximize the impact of this important work, so we convened the Coalition to Improve Diagnosis in order to partner with like-minded organizations in making diagnosis more accurate, safe, reliable, and efficient. It’s very exciting that the Coalition has grown to 23 major organizations. In addition to the individual actions each organization has committed to implement, we will work collectively to move some major initiatives that are still in the planning stage.”

What’s something unique or interesting about you?

“I have been fortunate to inherit many great things from my parents, but with them came a long list of chronic health conditions. In order to combat them, I took up running in my mid-forties and am hoping to run a marathon this year. It won’t be my first. In fact, for my 50th birthday, I ran a 50-mile ultramarathon, but it’s been more than 10 years since my last marathon, so I am really looking forward to the training challenge.”

Friday kicks off a week-long celebration of nurses nationwide sponsored by the American Nurses Association (ANA). The 2016 theme is “Culture of safety—It starts with you,” and the National Patient Safety Foundation (NPSF) would like to recognize the numerous ways nurses make a difference in the lives of patients and more specifically how they keep them safe from harm.

Like the ANA, NPSF recognizes the importance of creating a culture of safety. National Nurses Week is a great opportunity to acknowledge the many ways nurses contribute to safety culture.

Nurses Taking Initiative

“Nurses spend more time with patients than any other providers of care,” said Martha Cangany, a medical-surgical clinical nurse specialist at Franciscan St. Francis Health hospital in Indianapolis in a recent article. This is why nurse-led safety initiatives can be a powerful boost to patient care.

One example of nurses taking charge of the safety of patients occurred recently within seven Pennsylvania-area hospitals. While participating in the American Association of Critical-Care Nurses (AACN) training program, a group of nurses instituted a number of changes that led to the reduction of the average length of hospital stays for patients. Some of their initiatives included working on patient mobility and making improvements in team communication. These initiatives are vital steps forward in the movement to make medical care safer for everyone.

Top of the Ranks

Americans reported that they trust nurses more than any other profession, according to data from a 2015 Gallup poll. This isn’t a new finding as nurses have been ranked number one for the past 14 years.

Patients who are in the hospital or other care facility for a procedure, surgery, or accident, often are not there by choice. When they have a nurse who cares for them and brings a bit of positivity to the experience, it can make a difference in their care and recovery.

“Nurses are vital to creating and sustaining cultures of safety and ensuring safety of patients, families, and the workforce,” said Patricia McGaffigan, RN, MS, senior vice president and chief operating officer, NPSF. “And while nurses in any role are equally important to advancing safety, a large percent of nurses are serving in roles as patient safety officers, and managers, and an increasing number of nurses hold the Certified Professional in Patient Safety credential.”

Award-Winning RNs

The National Patient Safety Foundation plans to honor one exceptional nurse and one team of nurses in May at the NPSF Patient Safety Congress in Arizona. The honorees will receive the NPSF-DAISY Award, and we are excited to recognize the extraordinary work of these winners.

Read more about the 2016 honorees and the DAISY Award for Extraordinary Nurses.

​

NPSF and Nurses

“Nurses are leaders in advancing patient safety across the world and have been essential to the NPSF mission. They contribute regularly to the direction of our organization through participation on our boards, as members, and faculty for our webcasts and annual Congress,” said Tejal K. Gandhi, MD, MPH, CPPS, president and CEO of NPSF.

According to the Agency for Health Care Research and Quality’s PSNet, about 5% of hospitalized patients experience a medication error, and the rate may be even higher for patients treated in ambulatory settings. The use of barcodes on medications, mandated by the Food and Drug Administration back in 2004, has led to widespread adoption of barcode technology in hospitals, with studies showing broad reductions in medication errors.

Joe Melucci, MBA, RPh, medication safety officer at Ohio State University Wexner Medical Center (OSUWMC) and an alumnus of the AHA-NPSF Patient Safety Leadership Fellowship (class 12), points out that the literature shows that workarounds to barcode workflows are still too common in inpatient settings. For example, a nurse may scan the medication after, rather than before, administering it. Or the nurse may print a duplicate wrist band if it is perceived to be more practical to
scan an ID band that is not attached to the patient’s wrist.

“In some cases, the nurse may not realize the importance of barcoding as a safety measure,” says Mr. Melucci. “They may only consider it as a way of documenting what they have done.”

At OSUWMC, the team wanted to bring this technology to Emergency Departments, ambulatory infusion centers, and outpatient clinics. They addressed the challenges in inpatient care, eventually raising scanning compliance to their goal of 97%, or 97 of every 100 doses being scanned. That target allows for necessary exceptions, such as emergencies where taking the time to scan would compromise the care.

They recognized that different settings would present unique challenges. “The workflows are different, the pace is different. In procedural areas, they have to totally change the workflow to have orders in the system prior to the procedure to be able to have something to check the medication scan against,” says Mr. Melucci.

“Still other challenges are presented by dialysis units, because dialysate solution is considered a medical device, not a medication, and therefore does not exist in the pharmacy database. “We have to create medication records to allow nurses to scan those, because they can still make mistakes with grabbing the wrong concentration or the wrong formulation of solution,” says Mr. Melucci.

In psychiatric settings, patients can harm themselves with wrist bands, or the wrist band may become a distraction to the patient, interfering with their treatment.That’s where the question arose of whether it is ever okay to administer medication when a wrist band is not attached to the patient. “In the literature it is a no-no, because there is no evidence it is effective,” says Mr. Melucci, even though an organized method of scanning was created for this purpose.

One of the chief lessons learned in implementing barcode technology and sustaining compliance, says Mr. Melucci, is the importance of being transparent and consistent in the information provided to nurses and managers. It’s also important to know when to make an exception to the rule.

“Outpatient areas simply do not administer the same volume of medications as do inpatient areas,” he adds. “Making the investment in the technology and training reflects a deliberate decision to set the same standard of care for outpatient and inpatient settings.”

Representatives of Ohio State University Wexner Medical Center and Hospital Sisters Health System will present lessons learned and challenge attendees to think about exceptions to bar code scanning during a joint Breakout Session at the NPSF Patient Safety Congress. Find out more about the Congress agenda at www.npsf.org/congress.

Patients’ experience of care is increasingly thought to contribute to safety and health outcomes. A recent paper summarized 55 studies of patient experience, concluding in part that “patient experience is consistently positively associated with patient safety and clinical effectiveness across a wide range of disease areas, study designs, settings, population groups and outcome measures.”

Health care organizations committed to improving the patient experience of care may choose from a number of tools to help assess opportunities for improvement, including patient surveys and Patient and Family Advisory Committees.

Another tactic is patient and family shadowing. Unlike other methods of assessing experience, shadowing gives a picture of a patient’s experience in the moment, while it’s happening. “You’re seeing things from the end-user point of view, and in real-time, which is something that we really have not done in health care,” says Michelle Bulger, a trainer at the Patient and Family Centered Care (PFCC) Innovation Center of University of Pittsburgh Medical Center (UPMC).

Shadowing was developed under the guidance of Anthony M. DiGioia III, MD, a practicing orthopaedic surgeon and the medical director of the Bone and Joint Center at Magee Womens Hospital of UPMC. Dr. DiGioia is medical director and founder of the PFCC Innovation Center of UPMC and creator of the 6-step PFCC Methodology and Practice (PFCC M/P™), a process that, Bulger says, can help “take you from your current state of any care experience to a more ideal state of care. Shadowing comes to us from Step 3 of the PFCC Methodology – Evaluate the Current State – and it enables care givers to view care through the eyes of the patient and family.”

As Ms. Bulger explains, the patient and family are the only common denominator in the health care process, and they experience everything from inpatient care, outpatient care, and rehabilitation to making appointments, dealing with insurance, and more. By shadowing patients and families, care providers get a truer sense of the experience and how it can be improved, and can sometimes begin to effect improvements on the spot.

“We define caregiver as anyone in a care setting who directly or indirectly touches the patient and family experience,” says Ms. Bulger. “So, it’s not just the traditional care givers like doctors, nurses, and therapists; all of us are supporting the experience, whether we work in dietary, security, parking, facilities or elsewhere.”

Ms. Bulger emphasizes that shadowing is flexible in that different members of the care team can shadow the patient and family through different steps in their care. “It’s not necessary to tax any one shadower or any one patient, as long as you cover the entire care experience,” she says.

Ms. Bulger emphasizes that shadowing can also be an effective way to enhance patient safety, by revealing gaps or opportunities to reduce risk that are not easy to spot or appreciate from a care provider’s usual role. One example is of a patient still groggy from surgery trying to get out of bed. The person shadowing that patient was not only able to act in the moment to prevent a fall, but the protocol in that unit now calls for a companion to remain with the patient until they are cleared to get out of bed.

When caregivers shadow patients and families, they are acting on a one-to one basis, which generates empathy, which in turn drives an urgency to spark to change when they see something that could be improved. “What we find is that shadowing really re-engages the caregivers,” says Ms. Bulger “The connections made and perspective gained through shadowing reminds them of why they chose to be a care giver in the first place.

Ultimately, shadowing can be a driving force in the co-design of care, getting patient and family members’ direct input on how to improve processes for a better experience, and potentially better outcomes.

Michelle Bulger will be speaking on the topic of shadowing and training attendees on techniques during Breakout Session 103 at the 18th Annual NPSF Patient Safety Congress. Get details about the full Congress program at www.npsf.org/congress.

I was a cheerleader in junior high school. While it was fun at the time, that was enough of that.

Uninspired to take the same path in high school, I participated in both live theater and a variety of musical group activities (pep band, marching band, jazz band, symphonic band) that provided me with the chance to work with others toward shared goals. I thought I understood what teamwork was – until I grew up.

My first introduction to teamwork as a component of safety was as a staff member at the National Patient Safety Foundation. It was then that I was presented with the idea that teamwork was much more complicated than staying in line during marching practice. Granted, to be in a marching squad you had to commit to knowing your role, pay attention to what others were doing, achieve some level of reliable proficiency, give up your personal preferences as warranted for the greater good (is standing on a wind-swept football field in January in Chicago what any teenager wants to do?) and be aware that if you failed, the group could do poorly.

But, despite some similarities, teams and their role in safety go beyond that. In the safety sense of the word, teams rely on communication, mindfulness, and culture to enable their processes to be as highly reliable as possible during times of crisis. The focus on the flattening of hierarchy to encourage and support performance that is sensitive to, while capitalizing on, the humanness of people working together contributes to the reliability of collective action that expands beyond band practice in the 1970s. Trust and understanding create an environment that facilitates individual, group, and organizational learning from failures through a team’s commitment to feedback and open discussion.

It is no news to readers of this blog that team training models have been adopted from other high-risk industries to help health care evolve in the right direction. Commercial aviation and the military are the obvious examples. Given health care’s experiences with crew resource management and the Agency for Healthcare Research and Quality’s TeamSTEPPS initiative, the idea of building teamwork skills and the expectation that clinicians develop professional competencies in this area serves the logical foundation to infusing team practice and improvement into the frontline of care delivery. People are taught to do this well because poor teamwork can be catastrophic.

Explicit attention to the team roles of health care executives came later. And patient safety leaders—as they have done in other instances—looked outside health care for successful models. The business world certainly has had C-suite members that walk-the-talk of teamness. With credibility and integrity, those who model team behaviors and enable a culture at their company that support teamness provide examples to emulate its value. They demonstrate for health care executives the importance of purposely training and engaging a wide range of staff as team members.

Business schools and executive books champion teamwork skills as a foundational competency. The language and ideas of how to recognize and practice those skills from the business literature always resonated with me, a non-clinician. From that field, one author of particular interest is Harvard Professor Amy Edmondson. Edmondson’s writings caught my eye early on in my safety career. Her discussions about how organizational, unit, and peer culture and leadership affect staff willingness to report errors was inspiring to see—at a time when the value of that approach wasn’t as universally accepted as it is now (Edmondson 1996).

I distinctly remember working hard to get copies of her early articles (read pre-World Wide Web as we know it today). I still have the hard copies of those reports. Once a librarian, always a librarian.

Professor Edmondson’s publishing output since then covers a range of topics that touch on patient safety. Her articles on organizational and individual learning from failure are core resources in my readings list (Edmondson 2008, 2011). They provide foundation to my belief that knowledge management is a key driver of that learning. Edmondson’s 2012 Teaming is an excellent resource for considering how a culture of sharing what is known amongst people working closely together on a collective goal—no matter what box on the organizational chart represents them—is imperative to both team success and continuous learning (Edmondson 2012). She emphasizes that process, commitment, and leadership—both informal and at the executive level—must be present to translate learning into sustainable change in iterative constant fashion.

The sustained commitment to a culture of teams and teaming at variety of levels across a health care system can make that happen. True teams work together and share what they know and what they learn to achieve safety. Training and facilitating all health care workers—outside of rank and role—to participate in the cross-functional activity of teaming is vital to safety achievement. It offers health care yet another opportunity for synergy that presents clinicians, the organizations they work for and the patients they care for—with a chance to really make teamwork count.

Lorri Zipperer, MA, is the principal at Zipperer Project Management in Albuquerque, NM, specializing in patient safety and knowledge management efforts and bringing multidisciplinary teams together to envision, design, and implement knowledge sharing initiatives. Her latest collaboration was with The Risk Authority Stanford as a co-editor and contributing author of their 2016 publication Inside Looking Up. Contact her at Lorri@zpm1.com

In March of this year, a patient shot and killed a urologist in New Orleans, then turned the gun on himself. The incident was shockingly reminiscent of last year’s killing of a surgeon at a hospital in Boston by a distraught family member.

Although the murder of health care professionals is an extreme form of violence that is relatively rare, overall, health care professionals are at far greater risk than others of experiencing violence in the workplace. According to the Occupational Safety and Health Administration (OSHA), in the decade between 2002 and 2013, the rate of violent incidents requiring time off for the worker to recover was more than 4 times greater in health care than in other industries. OSHA data show that there are almost as many serious violent injuries in health care settings as there are in all other workplaces combined.

What do we know about the why of all this? Ann Scott Blouin, PhD, RN, FACHE, executive vice president, Customer Relations, at The Joint Commission (TJC), says part of it has to do with how open and accessible health care settings are, as well as the emotional state that patients and family members may be in while at a health facility.

“There are lots of entry points, making security more challenging. Also patients and family members in a health care setting often have reasons to be upset or concerned,” says Dr. Blouin. “Often health care providers need to have difficult conversations with patients and their families.”

Another factor is the incidence of patients having not only medical and surgical conditions, but also underlying mental illness, which can contribute to the risk of violence. And if patients, visitors, or family members typically live in an environment characterized by violence, they may bring that perspective and sometimes weapons into the health care setting, says Dr. Blouin.

If there is a bright spot, it is that many organizations now recognize this risk and are taking steps to educate the workforce and make health care safer for those on the front line of care.

The Joint Commission published a monograph in 2012 on the topic of workforce safety in health care and later this year plans to launch a web portal available to all with resources and tools. Among the resources will be the American Society for Healthcare Risk Management’s Workplace Violence Risk Assessment Tool.

In 2013, the National Patient Safety Foundation’s Lucian Leape Institute issued a report calling workforce safety a precondition to patient safety; Joint Commission fully supports that perspective and has published Sentinel Event Alerts and Quick Safety Alerts around the topics of escalating workplace violence.

If she could share only one piece of wisdom about this issue, Dr. Blouin says, “Don’t take your patients’ or your own personal safety for granted.” She points out that there are proven tactics to de-escalate a potentially violent situation, and that anyone can learn them.

“For those working in behavioral health, a standard part of the curriculum is to learn de-escalation techniques and be able to help people move from being angry and upset to a calmer state. Anyone regardless of their education and experience, whether a nurse, a physician, an environmental service worker, or a security officer, can benefit by learning these techniques,” she says.

Ann Scott Blouin will be speaking on the topic of workplace violence and tactics to counteract it during Breakout Session 301 at the NPSF Patient Safety Congress, May 24, in Scottsdale. Find out more about her session and the full program at www.npsf.org/congress.

For Kate Kovich, MS, OT, CPPS, vice president for patient safety and a 26-year veteran employee of Chicago-based Advocate Health Care, the pursuit of high reliability began with a medical error that resulted in the death of an infant.

“We were always very committed to safety,” says Ms. Kovich, “but after that event, we realized that we needed to fundamentally change our approach.”

And so the organization embarked on a strategic, multiphase plan to improve safety culture and reliability. In the three years since starting the program, Advocate has seen improvements in the AHRQ Safety Culture Survey scores at all of its 12 hospitals, a greater than 25% increase in reports of safety events and near-misses, and a 38% decline of serious safety events in its hospitals across the system.

The program put into place three years ago began with leadership training developed with the help of a consulting group and implemented throughout the system. “If you don’t start with your leaders, you’re never going to get to high reliability at the front line,” says Ms. Kovich.

At the same time, the organization began positioning safety as foundational to the care it provides. This involved a giant step in transparency: posting a calendar of “days since last serious safety event.” When an event occurs, and the calendar needs to change, Ms. Kovich’s office sends a brief e-mail to leaders, physicians, and staff to alert them to the risk without identifying the site, department, or patient.

Were they ever concerned about being so transparent? Yes, says Kovich, but “The presidents of the hospitals stressed the importance of getting this information to the front line. The president of the system responded and made the decision that it was a risk worth taking.”

For the past year, the program has focused on engaging those on the front line of care through training in high reliability principles and tools, and recruiting and training “safety coaches” for each unit or clinical department.

What surprised Ms. Kovich during this work? “I didn’t realize how vastly different the cultures of the organizations were from one to another; they move at different paces, so it is challenging to get an entire organization of this size to move together.” Still, she says, the response from leaders and the frontline health professionals has been positive.

Personally, Ms. Kovich says that one of the most important things she has learned over the past few years is the importance of influencing people in her organization—to connect them to the “why” of what they are doing—through story telling. “Telling stories is such an effective way to get people’s attention,” she says. “We never use the patient’s name. But we try to personalize it so it is not just an event we’re talking about, it’s somebody’s life we are holding in our hands.”

Kate Kovich will be discussing Advocate Health Care’s experience at the NPSF Patient Safety Congress. Get the details of Breakout Session 101: Implementing a Strategic Approach to High Reliability at the Sharp End and the rest of the Congress program at www.npsf.org/congress.

Patient Safety Awareness Week began yesterday, with more than 500 individuals having already taken the patient safety pledge. This week is a central part of the National Patient Safety Foundation’s United for Patient Safety campaign. It serves as dedicated time and a platform to increase awareness about patient safety among health professionals, policy makers, and the public.

But it’s also a time to celebrate some of the small wins along the way and the people who are working to advance patient safety in their organizations and in their communities.

So far we are seeing lots of creative ideas from many people and organizations, including

CHI St. Vincent Hospital in Arkansas is celebrating safety catches, sharing social media posts, and hosting safety coach crossword and other contests.

The 579th Medical Group at AFMS-Joint Base Anacastia-Bolling is also promoting safety via games, contests, and “room of horrors” in which staff can identify the safety lapses.

Dawn Evans, MSN, RN, patient safety officer at Barton Memorial Hospital (NV) and a member of the American Society of Professionals in Patient Safety at NPSF, compiled tips for patients, and published a commentary in her local paper.

The staff of AFMC Surgeon General donned hospital gowns in solidarity with patients and the We are all patients tactic of the United for Patient Safety Campaign.

In a special webcast moderated by NPSF President and CEO Dr. Tejal Gandhi, Drs. Don Berwick and Kaveh Shojania dove into questions about a new NPSF report and its recommendations for total systems safety and a culture of safety, with a call for leadership education being a key point of the discussion.

Should safety science be required learning for health system leaders and trustees? How do we more fully engage leaders in advancing patient safety? How do we get organizations to not just meet benchmarks, but to really work on the process of care?

Those were some of the questions posed to Don Berwick, MD, MPP, and Kaveh Shojania, MD, during a recent open webcast hosted by NPSF and moderated by Tejal Gandhi, MD, MPH, CPPS, president and CEO of NPSF. The session focused on the NPSF report, Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human, and was highlighted by question-and-answer sessions during which Drs. Berwick and Shojania expanded upon the report’s recommendations.

Dr. Berwick, former administrator of the Centers for Medicare and Medicaid Services and president emeritus of the Institute for Healthcare Improvement, and Dr. Shojania, director of the Centre for Quality Improvement and Patient Safety at the University of Toronto and editor-in-chief of BMJ Quality & Safety, served as co-chairs of the expert panel that produced the NPSF report.

The report’s 8 recommendations are:

Ensure that leaders establish and sustain a safety culture

Create centralized and coordinated oversight of patient safety

Create a common set of safety metrics that reflect meaningful outcomes

Increase funding for research in patient safety and implementation science

Address safety across the entire care continuum

Support the health care workforce

Partner with patients and families for the safest care

Ensure that technology is safe and optimized to improve patient safety

One of the first questions got to the heart of the safety culture conundrum: how can we capture the attention of CEOs and top management when it comes to safety? Acknowledging this as a “hard problem,” Dr. Berwick said that putting patients and families in the room with leaders and trustees is one of the most powerful and effective ways to get them engaged.

Long term, he said, leaders and trustees need training and education in safety, “just as they need to learn to read a balance sheet.” But for an immediate impact, nothing beats putting patients and families who have experienced harm in the same room with leaders and executives. “It’s very, very hard to turn away when that voice is in the room,” Dr. Berwick said.

He emphasized that the leaders need to hear patients and families in an “authentic way,” meaning not in a focus group type session, but in a format where the patients and families get to tell their stories. In answer to a follow-up question, he added that public forums, private executive sessions, and board meetings could all serve as a means of sharing patient stories. “The more the better,” he said.

One listener asked how educational preparation in patient safety has changed since To Err Is Human came out, and what more needs to be done. Dr. Berwick said the changes that have come have not been enough. “This is the new anatomy,” he said. “Safety and quality generally are no longer appropriately dealt with as add-ons to the professional skill set. It’s core; it’s essential.”

Would Dr. Berwick require trustees and executives to take a foundational course in safety science? “I’ll just say it’s really, really smart to do,” he said, stopping short of a requirement, but acknowledging that leaders and trustees have a duty to understand safety science, just as they need to understand financial stewardship of their organizations.

Other areas touched upon include

Reporting: Drs. Berwick and Shojania agreed that there has been an overemphasis on reporting for the sake of reporting, and that there needs to be more focus now on addressing the problems and recognizing which types of events are necessary to report every time. Dr. Shojania said that falls, for example, represent an epidemiologic problem, and there might not be value to reporting each and every one but instead focusing on systematic prevention.

Centralized oversight of patient safety: Dr. Berwick stopped short of calling for a new agency, like the National Transportation Safety Board, to oversee health care errors. He said there is a need for high levels of coordination, but that “a national reporting system may not add the value that some think if might…I’m a very strong fan of national leadership here, but national aggregation of data I think is something we need to approach with some caution.

Patient and family engagement: Dr. Shojania emphasized that many of the methods in use that are supposed to engage patients are superficial. True patient and family engagement needs to be authentic, and health care professionals could do a better job of characterizing what aspects of health care would most benefit from patient and family engagement.

In closing, Dr. Gandhi asked both presenters to pick their top 3 of the 8 recommendations. Both chose recommendations 1, Ensure that leaders establish and sustain a safety culture, and 6, support the health care workforce, among their top 3. Dr. Berwick added engaging patients and families to his list, while Dr. Shojania cited recommendation 8, Ensure that technology is safe and optimized to improve patient safety.

This is the first of a series of posts that will highlight past events or success stories that others may want to emulate.

With the United for Patient Safety campaign—and the countdown to Patient Safety Awareness Week—under way, now is a good time to look back at what some organizations did to mark the week in 2015.

Memorial Hermann Health System, a large, not-for-profit health system in Texas, put together multiple activities at a number of sites to engage staff in learning about patient safety. A founding member of the NPSF Stand Up for Patient Safety program, Memorial Hermann comprises 13 hospitals and numerous specialty programs.